OB EXAM 2
To be aware of potential risks to the laboring woman, the nurse understands that a breech presentation is associated with a. Umbilical cord compression b. More rapid labor c. A high risk of infection d. Maternal perineal trauma
ANS: A Feedback A The umbilical cord can be compressed between the fetal body and the maternal pelvis when the body has been born but the head remains within the pelvis. B Breech presentation is not associated with a more rapid labor. C There is no higher risk of infection with a breech birth. D There is no higher risk for perineal trauma with a breech birth.
37. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called a. vernix caseosa b. surfactant c. caput succedaneum d. acrocyanosis
ANS: A Vernix caseosa is a cheeselike substance on the skin. This protection is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 452 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
20. The new nurse learns that which condition related to decreased variability is considered benign? a. A periodic fetal sleep state b. Extreme prematurity c. Fetal hypoxemia d. Preexisting neurologic injury
ANS: A When the fetus is temporarily in a sleep state there is minimal variability present. Periodic fetal sleep states usually last no longer than 30 minutes. The other conditions would be considered conducive to abnormal variability. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 340 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is teaching a pregnant woman to reduce her intake of sodium. What products does the nurse teach the woman to avoid? (Select all that apply.) a. Products with the word "soda" in the ingredients b. Packaged gravy mixes c. Mayonnaise d. Cake mixes e. Fruit juices
ANS: A, B, D Products with the word "soda" in the ingredient list are high in sodium, as are packaged gravy mixes and cake mixes. Mayonnaise and fruit juice are lower in sodium and acceptable. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: Box 14.2 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
Which maternal factor may inhibit fetal descent and require further nursing interventions? a. Decreased peristalsis b. A full bladder c. Reduction in internal uterine size d. Rupture of membranes
ANS: B Feedback A Peristalsis does not influence fetal descent. B A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. C Contractions will reduce the internal uterine size in order to assist fetal descent. D Rupture of membranes will assist in the fetal descent.
To teach and support the woman in labor, the nurse explains that the strongest part of a labor contraction is the a. Increment b. Acme c. Decrement d. Interval
ANS: B Feedback A The increment is the beginning of the contractions until it reaches the peak. B The acme is the peak or period of greatest strength during the middle of a contraction cycle. C The decrement occurs after the peak until the contraction ends. D The interval is the period between the end of the contraction and the beginning of the next.
6. How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a. 50 to 75 b. 85 to 100 c. 100 to 110 d. 150 to 200
ANS: B Feedback A This amount is too little and does not provide adequate nutrition. B The term breastfed infant requires 85 to 100 kcal/kg per day. C The term newborn requires 100 to 110 kcal/kg to meet nutritional needs each day. D This amount may be too large and would lead to overfeeding.
10. The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called a(n) a. epidural. b. pudendal. c. local. d. spinal block.
ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 372 | Table 18.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
19. To prevent GI upset, patients should be instructed to take iron supplements a. on a full stomach. b. at bedtime. c. after eating a meal. d. with milk.
ANS: B Taking iron supplements at bedtime may reduce GI upset. Iron supplements are best absorbed if they are taken when the stomach is empty. Bran, tea, coffee, milk, and eggs may reduce absorption. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 261 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
7. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of a. increased pressure in the right atrium. b. increased pressure in the left atrium. c. decreased blood flow to the left ventricle. d. changes in the hepatic blood flow.
ANS: B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 427 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
23. The nurse should suspect uterine rupture if a. Fetal tachycardia occurs. b. The woman becomes dyspneic. c. Contractions abruptly stop during labor. d. Labor progresses unusually quickly.
ANS: C Feedback A Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. B This is not an early sign of a rupture. C A large rupture of the uterus will disrupt its ability to contract. D Contractions will stop with a rupture.
5. Which type of formula is not diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready-to-use d. Modified cow's milk
ANS: C Feedback A Formula should be well mixed to dissolve the powder and make it uniform. B Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. C Ready-to-use formula can be poured directly from the can into baby's bottle and is good (but expensive) when a proper water supply is not available. D Cow's milk is more difficult for the infant to digest and is not recommended, even if it is diluted.
9. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is ________ beats/min. a. 80 to 100 b. 100 to 120 c. 120 to 160 d. 150 to 180
ANS: C The average infant heart rate while awake is 120 to 160 beats/min. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Box 21.3 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
36. What information does the student learn about the newborn's developing cardiovascular system? a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) is on the third or fourth left intercostal space. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
ANS: C The newborns' PMI is found in the left third to fourth intercostal space. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 436 | Table 21.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
20. An important aspect about storage of breast milk is that it a. Can be frozen for up to 2 months b. Should be stored only in glass bottles c. Can be thawed and refrozen d. Can be kept refrigerated for 48 hours
ANS: D Feedback A Frozen milk should be kept for 1 month only. B Antibodies in the milk will adhere to glass bottles. Only rigid polypropylene plastic containers should be used. C It should not be refrozen. D If used within 48 hours after being refrigerated, breast milk will maintain its full nutritional value.
5. A pregnant woman's diet may not meet her need for folate. The nurse teaches the woman to take how much folate as a supplement each day? a. 100 to 200 mcg b. 200 to 400 mcg c. 400 to 600 mcg d. 400 to 800 mcg
ANS: D The current recommendation for folate (folic acid) is 400 to 800 mcg (0.4 to 0.8 mg) per day. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 260 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
14. When the newborn infant is fed, the most likely cause of regurgitation is a. placing the infant in a prone position after a feeding. b. the gastrocolic reflex. c. an underdeveloped pyloric sphincter. d. a relaxed cardiac sphincter.
ANS: D The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 430 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
2. Infant mortality for late preterm infants (34 to 36 weeks) is three times the rate of mortality for term infants. Is this statement true or false?
ANS: T This statement is correct. LPI infants may appear full term at birth; however, the appearance of the infant is deceiving. LPI infants have a mortality risk three times that of term infants for death from all causes.
Following an amniotomy, the priority nursing intervention is to A assess the fetal heart rate. B assess the color and amount of amniotic fluid. C assess the maternal vital signs including temperature. D place dry sheets and pads under the woman.
A An immediate and continuing risk is that the umbilical cord will slip down in the gush of fluid. The cord can be compressed between the fetal presenting part and the woman's pelvis. Nonreassuring FHR patterns may occur. Assessing the color and amount of amniotic fluid, monitoring maternal temperature, and keeping the woman dry are important interventions but not the priority intervention.
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because A there is a reduction of placental blood flow. B it produces a prolapsed cord. C it increases maternal renal blood flow. D it decreases maternal blood pressure.
A Hypertonic contractions can reduce placental blood flow and therefore reduce fetal oxygenation. Hypertonic contractions do not increase the risk for prolapsed cord, increased maternal renal blood flow, or decreased blood pressure.
The nurse noted that the woman's Bishop score was 9. This indicates that the woman A has a high likelihood of successful induction. B does not have a high likelihood of successful induction. C has a high likelihood of developing gestational diabetes. D does not have a high likelihood of developing gestational diabetes.
A The Bishop scoring system uses five factors to estimate cervical readiness for labor. A score of 8 or greater has a high level of successful induction. The Bishop scoring system does not refer to gestational diabetes.
The nurse notes that the hemoglobin level of a woman at 35 weeks of gestation is 11.5 g/dL. The nurse's next action should be to A. note that this is within the normal range for pregnancy. B. note that this is within the normal range for an average adult. C. call the physician; this shows mild anemia. D. recall that the RBC count increases slightly during pregnancy.
A The normal range of hemoglobin for pregnancy is greater than 11 g/dL in the first and third trimesters and greater than 10.5 g/dL in the second trimester. The normal range of hemoglobin for an average female is 12 to 16 g/dL. With pregnancy the levels are lower due to the increased iron requirements of the fetus. The RBC count decreases slightly because of hemodilution.
During her first prenatal visit to the clinic, a woman gives the following obstetric history: a boy born 9 years ago at full term, twin girls born 5 years ago at 36 weeks, a miscarriage at 9 weeks 2 years ago. The nurse correctly records her obstetric history as A. gravida 4, para 2, aborta 1. B. gravida 3, para 3, aborta 1. C. gravida 4, para 3, aborta 1. D. gravida 3, para 2, aborta 1.
A The woman is currently pregnant and has been pregnant 3 more times; that makes her a gravida 4. She has delivered two pregnancies after 20 weeks of gestation; that makes her a para 2. The twin girls count as one pregnancy. She delivered one pregnancy prior to 20 weeks; that makes her an aborta 1.
A woman is expecting her second child. She expressed concern to the nurse about how her 4-year-old will adapt to the new baby. The following are some suggestions the nurse should include in her teaching. Select all that apply. A. Come in and listen to the baby's heartbeat. B. Spend more time with grandmother to prepare him for being away from mother during the birth. C. Take a sibling class offered by the hospital. D. Decide which of your toys you would like to give to the new baby.
A, B, C A 4-year-old is curious about the changes in mother's body and the baby. By being included in the process, the child will not feel left out. It will also give the child an opportunity to ask questions. Children need to prepare for being away from mother during the birth and hospitalization. Starting early in the pregnancy to spend more time with the individual who will care for them will assist in the transition. Sibling classes provide an opportunity for children to discuss what newborns are like and what changes the new baby will bring to the family. Children need to be reassured that they are still maintaining an important role in the family. When they are asked to give up their possessions for the new baby, they may feel resentment.
Examples of situations when the birth attendant may do an episiotomy include the following. Select all that apply. A Fetal shoulder dystocia B Forceps- or vacuum extractor-assisted births C Breech presentation D Fetus in an occiput posterior position
A, B, D Fetal shoulder dystocia, forceps- or vacuum extractor-assisted births, or a fetus in an occiput posterior position are all indications for an episiotomy. Most breech presentations are delivered by cesarean.
1. The nurse is discussing infant care as part of the mother-infant's couplet discharge planning. The mother asks the nurse "When will my baby's cord fall off?" The nurse responds, "Your baby's cord should fall off by _______________ after birth."
ANS: 2 weeks Cord separation is influenced by several factors, including type of cord care, type of birth and other perinatal events. The average cord separation time is 10 to 14 days. Some dried blood may be seen at the umbilicus after separation.
1. Nurses need to know that when any woman is admitted to the hospital and is _____ to _____ weeks pregnant, she should receive antenatal glucocorticoids unless she has chorioamnionitis. Because these drugs require a 24-hour period to become effective, timely administration is essential.
ANS: 24; 34 All women between 24 and 34 weeks of gestation who are at risk for preterm birth within 7 days should receive treatment with a single course of antenatal glucocorticoids.
1. A newborn weight loss of _____% in a breastfeeding infant during the first 3 days of life should be investigated. Most often, the excessive weight loss is associated with poor breastfeeding techniques.
ANS: 7-8 Health care providers should evaluate and monitor infants who continue to lose weight after 5 days or who do not regain their birth weight by 14 days.
2. __________ is defined as long, difficult, or abnormal labor. It is caused by various conditions associated with the five factors affecting labor.
ANS: Dystocia A dysfunctional labor may result from problems with the powers of labor, the passenger, the passage, the psyche or a combination of these.
3. A nurse is caring for a patient in the active phase of labor. The woman's BOW spontaneously ruptures. Suddenly the woman complains of dyspnea and appears restless and cyanotic. Additionally, she becomes hypotensive and tachycardic. The nurse immediately suspects the presence of a(n) _____________.
ANS: amniotic fluid embolism Anaphylactoid syndrome of pregnancy (ASP) is more commonly known as amniotic fluid embolism. This is a rare but devastating complication of pregnancy. It is characterized by the sudden, acute onset of hypoxia, hypotension or cardiac arrest, and coagulopathy. ASP can occur during labor, birth, or within 30 minutes after birth. This clinical presentation is similar to that observed in patients with anaphylactic or septic shock. In both of these conditions, a foreign substance is introduced into the circulation.
2. Milk that gradually changes from colostrum to mature milk, appears over about 10 days after delivery. This is known as _____________ milk.
ANS: transitional The amount of transitional milk increases rapidly as the milk comes in. Immunoglobulins and proteins decrease while lactose, fat, and calories increase.
1. A newborn infant weighing 8 lb needs naloxone (Narcan). This infant should receive approximately _____ mg.
ANS: 0.36 The dose of naloxone is 0.1 mg/kg. This baby weighs 3.6 kg, so 0.1 3.6 = 0.36 mg. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 18.1 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
1. An infant was born weighing 7.2 pounds. Calculate this infant's oral intake needs. _______
ANS: 223.2-327 mL/day This infant weighs 3.27 kg. The range of intake for the first 3 days is 60 to 100 mL/kg/day. This infant needs 223.2 to 327 mL/day of fluid intake. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 434 | Box 21.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
While providing education to a primiparous woman regarding the normal changes of pregnancy, it is important for the nurse to explain that the uterus undergoes irregular contractions. These are known as _____________ contractions.
ANS: Braxton Hicks Irregular painless contractions occur throughout pregnancy, although many women do not notice them until the third trimester. Women who are unsure, who have 5 or 6 regular contractions within one hour, or who demonstrate other signs of labor should contact their provider.
Inquiring about past pregnancies is an important part of the nursing assessment. Women who have had a previous cesarean birth may request a trial of labor and a ______ delivery.
ANS: VBAC Although vaginal birth after cesarean is less common, it may be chosen for a variety of reasons. The nurse should be aware of the need for increased support of the woman in labor, and for complications that may occur.
The nurse is caring for a woman in labor at 39 weeks and 5 days of gestation. Her labor progress has slowed due to poor contractions. After discussion with the provider, a decision has been made that she is a good candidate for ___________ of labor
ANS: augmentation Augmentation of labor with oxytocin is considered when labor has begun spontaneously but progress has slowed or stopped. The rate of oxytocin may be lower than that of an induction.
In order to prevent neural tube defects, updated recommendations include an intake of 0.4 mg to 0.8 mg of ___________________ each day from one month prior to conception until 8 to 10 weeks of pregnancy.
ANS: folic acid Pregnant women should take 0.6 mg of folic acid daily for the duration of their pregnancy. Women who have given birth to an infant with a neural tube defect previously should take 4 mg of folic acid in the 4 weeks prior to pregnancy and throughout the first trimester.
A popular preinduction cervical ripening agent that is Food and Drug Administration (FDA) approved for the treatment of peptic ulcers is __________.
ANS: misoprostol Cytotec This synthetic prostaglandin tablet is used primarily for the prevention of peptic ulcers. Because of its low cost, stability, and ease of use, many facilities use this medication for cervical ripening and the induction of labor. The manufacturer does not intend to seek FDA approval for other indications; however, ACOG supports its use for these purposes.
During pregnancy many women become increasingly concerned about their ability to protect and provide for the fetus. This concern is often manifested as _____________.
ANS: narcissism Narcissism is an undue preoccupation with one's self and introversion (concentration on one's self and one's body). Selecting the right foods and clothing may be more important than ever before, out of concern for the growing fetus.
Which comment by a woman in her first trimester indicates ambivalent feelings? a. "I wanted to become pregnant, but I'm scared about being a mother." b. "I haven't felt well since this pregnancy began." c. "I'm concerned about the amount of weight I've gained." d. "My body is changing so quickly."
ANS: A Feedback A Ambivalence refers to conflicting feelings. B This does not reflect conflicting feelings. C By expressing concerns over a normal occurrence, the woman is trying to confirm the pregnancy. D The woman is trying to confirm the pregnancy when she expresses concerns over normal pregnancy changes. She is not expressing conflicting feelings.
Prenatal testing for the human immunodeficiency virus (HIV) is recommended for which women? a. All women, regardless of risk factors b. A woman who has had more than one sexual partner c. A woman who has had a sexually transmitted infection d. A woman who is monogamous with her partner
ANS: A Feedback A An HIV test is recommended for all women, regardless of risk factors. The incidence of perinatal transmission from an HIV-positive mother to her fetus ranges from 25% to 35%. Women who test positive for HIV can then be treated. B All women should be tested for HIV, although this patient is at increased risk of contracting the disease. C Regardless of past sexual history, all women should have an HIV test completed prenatally. D Although this patient is apparently monogamous, an HIV test is still recommended.
A pregnant woman's mother is worried that her daughter is not "big enough" at 20 weeks. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman's umbilicus. What should the nurse report to the woman and her mother? a. "The body of the uterus is at the belly button level, just where it should be at this time." b. "You're right. We'll inform the practitioner immediately." c. "When you come for next month's appointment, we'll check you again to make sure that the baby is growing." d. "Lightening has occurred, so the fundal height is lower than expected."
ANS: A Feedback A At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks of gestation is located at the level of the umbilicus. B This is incorrect information. At 20 weeks the uterus should be at the umbilical level. C By avoiding the direction question, this might increase the anxiety of both the mother and grandmother. D The descent of the fetal head (lightening) occurs in late pregnancy.
A gravida patient at 32 weeks of gestation reports that she has severe lower back pain. The nurse's assessment should include a. Observation of posture and body mechanics b. Palpation of the lumbar spine c. Exercise pattern and duration d. Ability to sleep for at least 6 hours uninterrupted
ANS: A Feedback A Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis. B Pregnancy should not cause alterations in the spine. Any assessment for malformation should be done early in the pregnancy. C Certain exercises can help relieve back pain. D Rest is important for well-being, but the main concern with back pain is to assess posture and body mechanics.
A patient notices that the doctor writes "positive Chadwick's sign" on her chart. She asks the nurse what this means. The nurse's best response is a. "It refers to the bluish color of the cervix in pregnancy." b. "It means the cervix is softening." c. "The doctor was able to flex the uterus against the cervix." d. "That refers to a positive sign of pregnancy."
ANS: A Feedback A Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the cervix, vagina, and labia, called Chadwick's sign. B Softening of the cervix is Goodell's sign. C The softening of the lower segment of the uterus (Hegar's sign) can allow the uterus to be flexed against the cervix. D Chadwick's sign is a probable indication of pregnancy.
The multiple marker screen is used to assess the fetus for which condition? a. Down syndrome b. Diaphragmatic hernia c. Congenital cardiac abnormality d. Anencephaly
ANS: A Feedback A The maternal serum level of alpha-fetoprotein is used to screen for Trisomy 18 or 21, neural tube defects, and other chromosomal anomalies. B The quadruple marker test does not detect this fetal anomaly. Additional testing, such as ultrasonography would be required to diagnose diaphragmatic hernia. C Congenital cardiac abnormality would most likely be identified during an ultrasound examination. D The quadruple marker test would not detect anencephaly.
Before the physician performs an external version, the nurse should expect an order for a a. Tocolytic drug b. Contraction stress test (CST) c. Local anesthetic d. Foley catheter
ANS: A Feedback A A tocolytic drug will relax the uterus before and during version, making manipulation easier. B CST is used to determine the fetal response to stress. C A local anesthetic is not used with external version. D The bladder should be emptied, but catheterization is not necessary.
A woman at 40 weeks of gestation should be instructed to go to a hospital or birth center for evaluation when she experiences a. A trickle of fluid from the vagina b. Thick pink or dark red vaginal mucus c. Irregular contractions for 1 hour d. Fetal movement
ANS: A Feedback A A trickle of fluid from the vagina may indicate rupture of the membranes requiring evaluation for infection or cord compression. B Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced. C This is a sign of false labor and does not require further assessment. D The lack of fetal movement needs further assessment.
What occurrence is associated with cervical dilation and effacement? a. Bloody show b. False labor c. Lightening d. Bladder distention
ANS: A Feedback A As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries. B Cervical dilation and effacement do not occur with false labor. C Lightening is the descent of the fetus toward the pelvic inlet before labor. D Bladder distention occurs when the bladder is not empted frequently. It may slow down the decent of the fetus during labor.
Which patient status is an acceptable indication for serial oxytocin induction of labor? a. Past 42 weeks' gestation b. Multiple fetuses c. Polyhydramnios d. History of long labors
ANS: A Feedback A Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. B Multiple fetuses overdistend the uterus, making induction of labor high risk. C Polyhydramnios overdistends the uterus, making induction of labor high risk. D History of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances.
Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Engagement b. Extension c. Internal rotation d. External rotation
ANS: A Feedback A Engagement occurs when the presenting part fully enters the pelvic inlet. B Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. C Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. D External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician? a. Persistent fetal bradycardia below 100 bpm b. Maternal pulse rate of 100 bpm c. Maternal blood pressure of 120/70 mm Hg d. Decrease in intensity of uterine contractions
ANS: A Feedback A Fetal bradycardia may indicate fetal distress and may require immediate intervention. B Maternal pulse rate may increase due to the pushing process. C This blood pressure is within expected norms for this stage of labor. D The birth is imminent at this point.
Immediately after the forceps-assisted birth of an infant, the nurse should a. Assess the infant for signs of trauma. b. Give the infant prophylactic antibiotics. c. Apply a cold pack to the infant's scalp. d. Measure the circumference of the infant's head.
ANS: A Feedback A Forceps delivery can result in local irritation, bruising, or lacerations of the fetal scalp. B Prophylactic antibiotics are not necessary with a forceps delivery. C This would put the infant at risk for cold stress and would be contraindicated. D Measuring the circumference of the head is part of the initial nursing assessment.
What is an essential part of nursing care for the laboring woman? a. Helping the woman manage the pain. b. Eliminating the pain associated with labor. c. Sharing personal experiences regarding labor and delivery to decrease her anxiety. d. Feeling comfortable with the predictable nature of intrapartal care.
ANS: A Feedback A Helping a woman manage the pain is an essential part of nursing care, because pain is an expected part of normal labor and cannot be fully relieved. B Labor pain cannot be fully relieved. C Decreasing anxiety is important, but managing pain is a top priority. D The labor nurse should always be assessing for unpredictable occurrences.
Leopold's maneuvers are used by practitioners to determine a. The best location to assess the fetal heart rate (FHR) b. Cervical dilation and effacement c. Whether the fetus is in the posterior position d. The status of the membranes
ANS: A Feedback A Leopold's maneuvers are often performed before assessing the FHR. These maneuvers help identify the best location to obtain the FHR. B Dilation and effacement are best determined by vaginal examination. C Assessment of fetal position is more accurate with vaginal examination. D A Nitrazine or ferning test can be performed to determine the status of the fetal membranes.
The nurse notes that a woman who has given birth 1 hour ago is touching her infant with the fingertips and talking to him softly in high-pitched tones. On the basis of this observation, the nurse should a. Document this evidence of normal early maternal-infant attachment behavior. b. Observe for other signs that the mother may not be accepting of the infant. c. Request a social service consult for psychosocial support. d. Determine whether the mother is too fatigued to interact normally with her infant.
ANS: A Feedback A Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. B These are signs of normal attachment behavior; no other assessment is necessary at this point. C There is no indication at this point that social service consult is necessary. The signs are of normal attachment behavior. D The mother may be fatigued but is interacting with the infant in an expected manner.
The nurse auscultates the fetal heart rate (FHR) and determines a rate of 152. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the FHR in 5 minutes because the rate is too high. c. Report the FHR to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.
ANS: A Feedback A The FHR is within the normal range, so no other action is indicated at this time. B The FHR is within the expected range; reassessment should occur, but not in 5 minutes. C The FHR is within the expected range; no further action is necessary at this point. D The sex of the baby cannot be determined by the FHR.
To adequately care for a laboring woman, the nurse should know that the _____ stage of labor varies the most in length. a. First b. Second c. Third d. Fourth
ANS: A Feedback A The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first pregnancy, the first stage of labor can take up to 20 hours. B The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. C The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. D The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.
A laboring woman is lying in the supine position. The most appropriate nursing action is to a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine if fetal tachycardia is present.
ANS: A Feedback A The woman's supine position may cause the heavy uterus to compress her inferior vena cava, reducing blood return to her heart and reducing placental blood flow. This problem is relieved by having her turn onto her side. B Elevating her legs will not relieve the pressure from the inferior vena cava. C This position may produce hypotension in the woman, but the action should be to prevent this from happening, not to assess for the problem. D If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side.
8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs
ANS: A Feedback A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases fetal oxygen supply. B Maternal fatigue usually does not decrease uterine blood flow. C Maternal sedation will sedate the fetus but should not decrease blood flow. D Tocolytic drugs decrease contractions. This will increase uterine blood flow.
19. A breastfeeding mother who was discharged yesterday calls to ask about a tender, hard area on her right breast. The nurse's first response should be a. "Try massaging the area and apply heat, as this is probably a plugged duct." b. "Stop breastfeeding because you probably have an infection." c. "Notify your doctor so he can start you on antibiotics." d. "This is a normal response in breastfeeding mothers."
ANS: A Feedback A A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. B Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation. C These are not the signs of an infection, so antibiotics are not indicated. D This is a normal deviation but requires intervention to prevent further complications.
22. What is the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline? a. Fetal heart rate, maternal pulse, and blood pressure b. Maternal temperature and odor of amniotic fluid c. Intake and output d. Maternal blood glucose
ANS: A Feedback A All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. B These are important if the membranes have ruptured, but they are not relevant to the medication. C This is not an important assessment to monitor for side effects of terbutaline. D This is not an important assessment to monitor for side effects of terbutaline.
13. A woman in preterm labor at 30 weeks of gestation receives two 12 mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to a. Stimulate fetal surfactant production. b. Reduce maternal and fetal tachycardia associated with ritodrine administration. c. Suppress uterine contractions. d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
ANS: A Feedback A Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. B Inderal would be given to reduce the effects of ritodrine administration. C Betamethasone has no effect on uterine contractions. D Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
28. The best reason for recommending formula over breastfeeding is that a. The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. The mother lacks confidence in her ability to breastfeed. c. Other family members or care providers also need to feed the baby. d. The mother sees bottle-feeding as more convenient.
ANS: A Feedback A Breastfeeding is contraindicated when mothers have certain viruses, are undergoing chemotherapy, or are using/abusing drugs. B Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. The key to encouraging these mothers to breastfeed is anticipatory guidance beginning as early as possible in pregnancy. C A major barrier for many women is the influence of family and friends. She may view formula feeding as a way to ensure that the father and other family members can participate. Each encounter with the family is an opportunity for the nurse to educate, dispel myths and clarify information regarding the benefits of breastfeeding. D Many women see bottle-feeding as more convenient and less embarrassing than breastfeeding. They may also see breastfeeding as incompatible with an active social life. There may be modesty issues related to feeding the infant in public. Although concerning, these are not legitimate reasons to formula-feed an infant. Often this decision is made without complete information regarding the benefits of breastfeeding.
26. According to the recommendations of the American Academy of Pediatrics (AAP) on infant nutrition a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed infants. c. If infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula. d. After 6 months, mothers should shift from breast milk to cow's milk.
ANS: A Feedback A Breastfeeding/human milk should also be the sole source of milk for the second 6 months. B Infants start on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. C If infants are weaned from breast milk before 12 months, they should receive iron-fortified formula, not cow's milk. D Breastfeeding/human milk should also be the sole source of milk for the second 6 months.
23. A new mother asks if she should feed her newborn colostrum, because it is not "real milk." The nurse's best answer is that a. Colostrum is high in antibodies, protein, vitamins, and minerals. b. Colostrum is lower in calories than milk and should be supplemented by formula. c. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d. Colostrum is unnecessary for newborns.
ANS: A Feedback A Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. B Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. C It is important for the mother to feel comfortable in this role before discharge, but the importance of the colostrum to the infant is top priority. D Colostrum provides immunities and enzymes necessary to clean the gastrointestinal system, among other things.
4. Birth for the nulliparous woman with a fetus in a breech presentation is usually by a. Cesarean delivery b. Vaginal delivery c. Forceps-assisted delivery d. Vacuum extraction
ANS: A Feedback A Delivery for the nulliparous woman with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so that the infant can breathe. B The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so the infant can breathe. C The physician may assist rotation of the head with forceps. A cesarean birth may be required. D Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult.
2. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is true? Bottle-feeding using commercially prepared infant formulas a. Increases the risk that the infant will develop allergies b. Helps the infant sleep through the night c. Ensures that the infant is getting iron in a form that is easily absorbed d. Requires that multivitamin supplements be given to the infant
ANS: A Feedback A Exposure to cow's milk poses a risk of developing allergies, eczema, and asthma. B This is a false statement. Newborns should be fed during the night regardless of feeding method. C Iron is better absorbed from breast milk than from formula. D Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.
22. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. What statement is valid? a. A premature infant more easily digests breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should only pump as much as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night.
ANS: A Feedback A Human milk is the ideal food for preterm infants, with benefits that are unique in addition to those received by term, healthy infants. Greater physiologic stability occurs with breastfeeding compared with formula feeding. B Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mother's milk ejection reflex. C To establish an optimal milk supply, the mother should be instructed to pump eight to 10 times a day for 10 to 15 minutes on each breast. D The mother should be instructed to pump eight to 10 times a day for 10 to 15 minutes on each breast.
3. Which technique is least effective for the woman with persistent occiput posterior position? a. Lie supine and relax. b. Sit or kneel, leaning forward with support. c. Rock the pelvis back and forth while on hands and knees. d. Squat.
ANS: A Feedback A Lying supine increases the discomfort of "back labor." B A sitting or kneeling position may help the fetal head to rotate to occiput anterior. C Rocking the pelvis encourages rotation from occiput posterior to occiput anterior. D Squatting aids both rotation and fetal descent.
29. The nurse providing couplet care should understand that nipple confusion results when a. Breastfeeding babies receive supplementary bottle feedings. b. The baby is weaned too abruptly. c. Pacifiers are used before breastfeeding is established. d. Twins are breastfed together.
ANS: A Feedback A Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks, because the two require different skills. B Abrupt weaning can be distressing to mother and/or baby but should not lead to nipple confusion. C Pacifiers used before breastfeeding is established can be disruptive, but this does not lead to nipple confusion. D Breastfeeding twins require some logistical adaptations, but this should not lead to nipple confusion.
11. Nurses can help parents deal with the issue and fact of circumcision if they explain a. The pros and cons of the procedure during the prenatal period b. That the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised c. That circumcision is rarely painful and that any discomfort can be managed without medication d. That the infant will likely be alert and hungry shortly after the procedure
ANS: A Feedback A Parents need to make an informed choice regarding newborn circumcision based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. B The AAP and other professional organizations note the benefits, but stop short of recommendation for routine circumcision. C Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. D Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures.
15. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally the visit is scheduled between 24 and 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.
ANS: A Feedback A The home visit is ideally scheduled during the first 24 to 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. B Because home visits are expensive, they are not available in all geographic areas. C Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. D When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.
30. Many types of breast pumps are available, varying in price and effectiveness. Before either renting or purchasing a pump, the new mother would benefit from counseling by a nurse or lactation consultant to determine the most appropriate pump to suit her needs. The mother who is pumping for an occasional bottle would be most suited for which type of pump? a. Manual or hand pump b. Hospital grade pump c. Electric self-cycling double pumps d. Smaller electric or battery operated pump
ANS: A Feedback A These are the least expensive and can be the most appropriate choice for mothers pumping for the occasional bottle. B Full service electric or hospital grade pumps most closely duplicate the sucking action of the breastfeeding infant. These are used when mother and baby (preterm or sick) are separated for long periods. C Self-cycling pumps are easy to use, efficient and designed for working mothers. D Smaller pumps operated with a battery are typically used when pumping occasionally.
31. What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth? a. Puncture the lateral pad of the heel. b. Obtain a sample from the umbilical cord. c. Puncture a fingertip. d. Obtain a laboratory chemical determination.
ANS: A A drop of blood obtained by heel stick is the quickest method of glucose screening. The calcaneus bone should be avoided as osteomyelitis may result from injury to the foot. Most umbilical cords are clamped in the delivery room and are not available for routine testing. A neonate's fingertips are too fragile to use for this purpose. Laboratory chemical determination is the most accurate but the lengthiest method. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 449 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
4. A nurse manager plans staffing for the Labor and Delivery unit. How does the available staff influence the selection of either continuous electronic or intermittent auscultation as the fetal monitoring method? a. There must be a 1:1 nurse-to-patient ratio regardless of the method used. b. Staffing patterns do not influence fetal monitoring choices. c. Use of intermittent auscultation requires a lower nurse-to-patient ratio. d. More nurses are needed when electronic fetal monitoring is used.
ANS: A A one-to-one ratio is needed during the second stage of labor or if a high-risk condition exists, regardless of the monitoring method used. Intermittent auscultation is more staff-intensive. Less nursing time is needed with electronic monitoring, giving the nurse more time for teaching and supporting the laboring woman. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 336 OBJ: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment
31. What statement by the woman after a childbirth education class demonstrates that she needs more information? a. "I'm having a pudendal block so control my labor pain." b. "I may get a headache after a subarachnoid block." c. "I don't want IV opioids as they may cause breathing problems." d. "Some anesthetic agents may cause itching but it can be treated."
ANS: A A pudendal block numbs the lower vagina and perineum for vaginal birth. There is no relief of labor pain because it is done just before birth. This woman needs further education. The other statements are all accurate. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: Table 18.2 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
13. A patient has the nursing diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to diet choices inadequate to meet nutrient requirements of pregnancy. What goal is most appropriate for this diagnosis? a. Weight change from 135 pounds to 165 pounds at delivery b. Take daily supplements consistently. c. Decrease intake of snack foods. d. Increase intake of complex carbohydrates.
ANS: A A weight gain of 30 lb is one indication that the patient has gained a sufficient amount for the nutritional needs of pregnancy. A daily supplement is not the best goal for this patient. It does not meet the basic need of proper nutrition during pregnancy. Decreasing snack foods may be the problem and should be assessed. However, assessing the weight gain is the best method of monitoring nutritional intake for this pregnancy. Increasing the intake of complex carbohydrates is important for this patient, but monitoring the weight gain should be the end goal. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: p. 256 | Table 14.1 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
The nurse is explaining the results of a maternal serum alpha-fetoprotein screening test to the woman. The nurse knows the woman does not understand the teaching if she says A. "Since the levels were within normal limits, I know the baby does not have any anomalies." B. "I know that the levels are high, but that does not always mean something is wrong with the baby." C. "Since I am not sure about the date of my last menstrual period, the test results cannot be accurately interpreted." D. "Since the levels are low, my baby may have Down syndrome."
ANS: A A. Alpha-fetoprotein levels are a screening test. Some fetal defects are covered by skin and do not produce elevated levels of AFP. B. MSAFP levels are a screening test and must be viewed as the first step in a series of diagnostic procedures that are indicated if abnormal concentrations are found. C. Inaccurate estimation of gestational age can result in false-positive or false-negative results. D. Low levels are an indication of Down syndrome; more testing is indicated.
On which aspect of fetal diagnostic testing do parents usually place the most importance? A. Safety of the fetus B. Duration of the test C. Cost of the procedure D. Physical discomfort caused by the procedure
ANS: A A. Although all of these are considerations, parents are usually most concerned about the safety of the fetus. B. Duration of the test is a consideration; however, parents are usually most concerned about the safety of the fetus. C. Cost of the procedure is a consideration; however, parents are usually most concerned about the safety of the fetus. D. Physical discomfort caused by the procedure is a consideration; however, parents are usually most concerned about the safety of the fetus.
The nurse is teaching a woman in her second trimester about an upcoming ultrasonography exam. The nurse knows her teaching has been successful when the woman states A. "I will drink several glasses of water about an hour before I come in for the test." B. "I will empty my bladder just before the test." C. "I will not eat or drink anything for 8 hours prior to coming in for the test." D. "I will plan on staying at the doctor's office for about 2 hours after the test so you can check to make sure the baby was not harmed during the procedure."
ANS: A A. Drinking several glasses of clear fluid 1 hour before the time of the examination will produce a full bladder. The bladder will displace the intestines and elevate the uterus for better visibility. B. The woman needs a full bladder prior to the exam in order to displace the intestines and elevate the uterus for better visibility. C. It is not necessary to be NPO for 8 hours prior to this exam. D. No fetal postprocedure assessments are necessary.
When is the most accurate time to determine gestational age through ultrasound? A. First trimester B. Second trimester C. Third trimester D. There is no difference in accuracy between the trimesters
ANS: A A. During the first trimester, measurement of the crown-rump length of the embryo is the most reliable indicator of gestational age. . B. Gestational age determination by ultrasonography is increasingly less accurate after the first trimester. C. Estimating fetal age by ultrasound after 32 weeks is subject to major error. D. Gestational age determination by ultrasonography is increasingly less accurate after the first trimester.
32. A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called a. acrocyanosis. b. erythema neonatorum. c. harlequin color. d. vernix caseosa.
ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 428 | Figure 21.2 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
11. A pregnant patient would like to know a good food source of calcium other than dairy products. Which answer by the nurse is best? a. Legumes b. Yellow vegetables c. Lean meat d. Whole grains
ANS: A Although dairy products contain the greatest amount of calcium, it also is found in legumes, nuts, dried fruits, and some dark green leafy vegetables. Yellow vegetables are rich in vitamin A. Lean meats are rich in protein and phosphorus. Whole grains are rich in zinc and magnesium. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 258 | Table 14.3 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
8. The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic analgesia in the newborn is a. respiratory depression. b. bradycardia. c. acrocyanosis. d. tachypnea.
ANS: A An infant delivered within 5 hours of maternal analgesic administration (timing depends on drug used) is at risk for respiratory depression from the sedative effects of the opioid. Bradycardia, acrocyanosis, and tachypnea are not anticipated side effects of maternal analgesics. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 365 | Table 18.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. The nurse should alert the provider when a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant's blood glucose is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour.
ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. The nurse needs to notify the provider. Acrocyanosis is an expected finding during the early neonatal life. A blood glucose of 45 mg/dL is within normal range for a newborn. Infants enter the period of deep sleep when they are about 1 hour old. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 452 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. Excessive anxiety in labor heightens the woman's sensitivity to pain by increasing a. muscle tension. b. blood flow to the uterus. c. the pain threshold. d. rest time between contractions.
ANS: A Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman's brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. It can also decrease blood flow to the uterus, the pain threshold, and the amount of rest the mother gets between contractions. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 356 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
3. Nurses can prevent evaporative heat loss in the newborn by a. drying the baby after birth and wrapping the baby in a dry blanket. b. keeping the baby out of drafts and away from air conditioners. c. placing the baby away from the outside wall and the windows. d. warming the stethoscope and nurse's hands before touching the baby.
ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 427 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
23. The nurse teaching a childbirth preparation class teaches the participants that the first type of breathing technique used in labor is called a. slow-paced. b. modified-paced. c. patterned-paced. d. pant-blow.
ANS: A Breathing for the first stage of labor consists of a cleansing breath and various breathing techniques known as paced breathing. The first type used in labor is the slow-paced. Modified-paced breathing is used when the slow-paced breathing is no longer effective Patterned-paced breathing is used later in the labor and has the woman focusing on a pattern of breathing. Pant-blow breathing can be used to prevent pushing before the cervix is completely dilated. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 359 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
30. A woman has received an epidural block. What action by the nurse takes priority? a. Instruct her to call for help when getting out of bed. b. Assess the woman for a post-procedure headache. c. Determine type and time of last oral intake. d. Administer metoclopramide within the first hour.
ANS: A Due to variable leg strength and sensation with an epidural block, the woman who is able to get out of bed needs to call for assistance for safety. Post-procedure headaches are associated with subarachnoid blocks. Oral intake and pro-motility agents are important for the woman having general anesthesia. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 18.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
22. In the low-risk patient assessments for variability and periodic changes if using the fetal monitor should be done how often? a. Every 15 to 30 minutes b. Every 5 to 15 minutes c. Every 30 to 60 minutes d. Only before and after ambulation
ANS: A During the active first stage of labor, FHR should be assessed every 15 to 30 minutes just after a contraction. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 385 | Box 17.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment
21. Which nutritional recommendation about fluids is accurate? a. A woman's daily intake should be 8 to 10 cups, and most of it should be water. b. Coffee should be limited to no more than 2 cups, but tea and cocoa can be consumed without worry. c. Of the artificial sweeteners, only aspartame has not been associated with any maternity health concerns. d. Water with fluoride is especially encouraged because it reduces the child's risk of tooth decay.
ANS: A Eight to 10 cups is the standard for fluids; however, they should be the right fluids. All beverages containing caffeine, including tea, cocoa, and some soft drinks, should be avoided or should be drunk only in limited amounts. Artificial sweeteners, including aspartame, have no ill effects on the normal mother or fetus. However, mothers with phenylketonuria (PKU) should avoid aspartame. No evidence indicates that prenatal fluoride consumption reduces childhood tooth decay. However, it still helps the mother. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 262 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
18. A woman received an epidural anesthetic and now her blood pressure is 88/64 mm Hg. What action by the nurse takes priority? a. Turn the woman to the left side. b. Place a wedge under the woman's right hip. c. Call the provider or nurse-anesthetist immediately. d. Decrease the intravenous infusion rate.
ANS: A If hypotension occurs after administration of an epidural, turn the patient to the left lateral side-lying position, and infuse intravenous crystalloids. These actions will improve placental blood flow. Oxygen administration is also recommended, but placing the patient on the left side takes priority. The providers should be notified after corrective actions have occurred. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 373 | Table 18.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
40. An infant has been exposed to cold stress. After taking measures to warm the infant, what action does the nurse perform next? a. Obtain a blood glucose reading. b. Listen to the infant's lungs. c. Document the warming interventions. d. Determine how the baby got cold.
ANS: A In trying to maintain temperature, the infant expends a lot of energy, using glucose. The infant is at risk of hypoglycemia, so a glucose reading should be obtained. Documenting and investigating the incident are important but need to wait until the glucose is obtained and actions taken if needed. Listening to the lungs is not specifically needed in this case since there is no indication that the infant has respiratory distress. This action can occur later as well. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 429 | Box 21.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment
27. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70 F. c. Undress the infant completely for assessments so they can be finished quickly. d. Take the rectal temperature every hour to detect early changes.
ANS: A Padding the scale prevents heat loss from the infant to a cold surface by conduction. Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. Hourly assessments are not necessary for a normal newborn with a stable temperature. Rectal temperatures are usually not done on the newborn. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 428 | Figure 21.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
6. The student nurse learns that in fetal circulation, the pressure is greatest in the a. right atrium. b. left atrium. c. hepatic system. d. pulmonary veins.
ANS: A Pressure in fetal circulation is greatest in the right atrium, which allows a right-to-left shunting that aids in bypassing the lungs during intrauterine life. The pressure increases in the left atrium after birth and will close the foramen ovale. The liver does not filter the blood during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein during fetal life. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 426 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
20. Which statement by a patient indicates that she understands the role of protein in her pregnancy? a. "Protein will help my baby grow." b. "Eating protein will prevent me from becoming anemic." c. "Eating protein will make my baby have strong teeth after he is born." d. "Eating protein will prevent me from being diabetic."
ANS: A Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary glands, and placenta; the increase in the maternal blood volume; and the formation of amniotic fluid. Iron intake prevents anemia. Calcium intake is needed for fetal bone and tooth development. Eating protein will not prevent diabetes. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: p. 257 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
18. Which statement correctly describes the nurse's responsibility related to electronic monitoring? a. Teach the woman and her support person about the monitoring equipment, and discuss any questions they have. b. Report abnormal findings to the physician before initiating corrective actions. c. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place. d. Document the frequency, duration, and intensity of contractions measured by the external device.
ANS: A Teaching is an essential part of the nurse's role. Corrective actions should be initiated first in order to correct abnormal findings as quickly as possible. The support person should be encouraged to assist with the comfort measures. Electronic monitoring will record the contractions and FHR response. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 347 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
21. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp
ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. The plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, the infant's toes curl over the nurse's finger. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 448 | Table 21.3 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
13. The fetal heart rate baseline increases 15 beats per minute after vibroacoustic stimulation. What action by the nurse is most appropriate? a. Reassure the family the finding is normal. b. Prepare to assist with obtaining cord blood gases. c. Position the woman on her left side. d. Administer oxygen at 4 L via nasal cannula.
ANS: A The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) over baseline of 15 bpm for 15 seconds or more. The nurse reassures the family that this finding is normal. The other actions are not warranted. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 346 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
7. The best time to teach nonpharmacologic pain control methods to an unprepared laboring woman is during which phase? a. Latent phase b. Active phase c. Transition phase d. Second stage
ANS: A The latent phase of labor is the best time for intrapartum teaching, because the woman is usually anxious enough to be attentive, yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the delivery. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 357 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
10. In which situation is a baseline fetal heart rate of 160 to 170 beats per minute considered a normal finding? a. The fetus is at 28 weeks of gestation. b. The mother has been given an epidural block. c. The mother has a history of fast labors. d. The mother has mild preeclampsia but is not in labor.
ANS: A The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Any change in the FHR with an epidural is not considered an expected outcome. Fast labors should not alter the FHR normally. Preeclampsia should not cause a normal elevation of the FHR. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 340 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
19. The priority nursing intervention for the patient who has received an epidural narcotic is a. monitoring respiratory rate hourly. b. administering analgesics as needed. c. monitoring blood pressure every 4 hours. d. assessing the level of anesthesia.
ANS: A The possibility of respiratory depression exists for up to 24 hours after administration of an epidural narcotic. The nurse should monitor the woman's respiratory rate hourly during this time frame. Epidural narcotic should be enough pain relief that further medication is not necessary. Administering any other narcotic may cause an overdose. The patient's blood pressure needs to be monitored. However, that is not the major concern with this medication. The epidural narcotic should provide pain relief but not anesthesia. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 367 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
22. A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate? a. Prepare to assist with a blood patch procedure. b. Give the woman IV opioid pain medications. c. Increase the rate of her nonadditive IV fluids. d. Place a cool cloth on her forehead and dim the room lights.
ANS: A The subarachnoid block may cause a postspinal headache due to loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture ("blood patch"), it forms a seal over the hole to stop leaking of cerebrospinal fluid. The spinal anesthesia makes further narcotic administration inadvisable at this time. Increasing IV fluid rate is not needed for headache. A cool cloth and dim lights may be very comforting but will not eliminate this severe headache. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 373 | Table 18.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
21. The student nurse is working with a laboring woman. What action by the student requires the registered nurse to intervene? a. Placing the woman in a supine position b. Assisting the woman to a sitting position c. Turning the woman to a side-lying position d. Providing safety while the woman labors while standing
ANS: A The supine position allows the heavy uterus to compress the inferior vena cava and can reduce placental blood flow, compromising fetal oxygen supply. The nurse should intervene to position the woman in any of the other positions, which are all appropriate for labor if no contraindications exist. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 363 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
5. A student nurse is placing a tocotransducer on a woman for electronic fetal monitoring. What action by the student indicates to the registered nurse that the student understands the procedure? a. Places the tocotransducer over the uterine fundus b. Prepares sterile field for fetal scalp electrode placement c. Positions the tocotransducer on the woman's upper arm d. Attaches the tocotransducer to the woman's lower abdomen
ANS: A The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. No sterile field is needed. The tocotransducer is not placed on the upper arm or lower abdomen. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: p. 338 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
34. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."
ANS: A This describes a meconium stool, which the nurse should educate the father about. It is not a transitional stool nor does it indicate bleeding. Telling the father not to worry about it is belittling and does not provide information. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 451 | Box 21.5 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
2. In order to help patients manage discomfort and pain during labor, nurses should be aware that a. the predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. somatic pain is the extreme discomfort between contractions. c. the somatic pain of the second stage of labor is more generalized and related to fatigue. d. pain during the third stage is a somewhat milder version of the second stage.
ANS: A This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Somatic pain is a faster, sharp pain. Somatic pain is most prominent during late first-stage labor and during second-stage labor as the descending fetus puts direct pressure on maternal tissues. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 355 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
1. The nurse sees this pattern on the fetal monitor. What action by the nurse is most appropriate? a. Apply oxygen via face mask, and position the woman on her left side. b. Document the findings in the chart along with maternal vital signs. c. Prepare to start an infusion of oxytocin per unit protocol. d. Decrease the rate of the woman's IV maintenance fluids.
ANS: A This tracing shows a late deceleration. The mother should be given oxygen and positioned on her left side. The findings should be documented, but only after interventions have occurred. Oxytocin would increase uterine activity (and increase stress on the fetus) so should not be started, or if already running, discontinued. IV fluids should be increased. PTS: 1 DIF: Cognitive Level: Analysis REF: Figure 17.10 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. Which maternal condition is considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix is dilated to 4 cm c. External monitors are currently being used d. Fetus has a known heart defect
ANS: A To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm permits the insertion of fetal scalp electrodes and intrauterine catheter. The external monitor can be discontinued after the internal ones are applied. A compromised fetus should be monitored with the most accurate monitoring devices. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 338 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
2. Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (select all that apply) a. Unwrap the infant. b. Change the diaper. c. Talk to the infant. d. Slap the infant's hands and feet. e. Apply a cold towel to the infant's abdomen.
ANS: A, B, C Feedback Correct These are appropriate techniques to use when trying to wake a sleepy infant. Incorrect This is not appropriate. The parent can rub the infant's hands or feet to wake the infant. Applying a cold towel to the infant's abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant's face to wake the infant.
5. The nurse has taught a vegetarian pregnant woman foods that are high in iron. Which menu selections demonstrate good understanding of the material? (Select all that apply.) a. Cooked soybeans b. Canned stewed tomatoes c. Raisin bran cereal d. White bread e. Peaches
ANS: A, B, C Cooked soybeans, canned stewed tomatoes, and Raisin Bran cereal are all high in iron. White bread and peaches are not. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: Table 14.4 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity
4. Which of the following factors place the intrapartum woman at risk for complications during labor and delivery? (Select all that apply.) a. Prolonged rupture of membranes b. Chorioamnionitis c. Fever d. History of stillbirth e. Drug use
ANS: A, B, C Prolonged rupture of membranes, Chorioamnionitis, and fever are specific to the intrapartum period. Stillbirths and drug use are problems found in the antepartum period. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Box 17.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
2. When assessing cultural influences on a pregnant woman's diet, which actions by the nurse are best? (Select all that apply.) a. Learn about traditional foods in that culture. b. Ask the woman how she prepares food. c. Determine if there are specific "pregnancy" foods. d. Assess how traditional the woman is. e. Find out what support she has locally.
ANS: A, B, C The nurse should ask about traditional foods in her culture and how she (or others) prepare the food. In some cultures, specific foods are eaten during pregnancy, and the nurse should determine this as well. Assessing how traditional the woman is may or may not be helpful; some women who are not traditional at all return to their cultural practices during pregnancy for a number of reasons. Support systems are not related to food. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 263 OBJ: Integrated Process: Culture and Spirituality MSC: Client Needs: Health Promotion and Maintenance
1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cures indicating pain, measures should be taken to manage the infant's pain. Examples of nonpharmacologic pain management techniques include (select all that apply) a. Swaddling b. Nonnutritive sucking (pacifier) c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen
ANS: A, B, C, D Feedback Correct These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Other interventions include soothing music, dim lighting and speaking to the infant in a quiet voice. Incorrect Acetaminophen is a pharmacologic method of treating pain.
3. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? Select all that apply. a. Breast tenderness b. Warmth in the breast c. An area of redness on the breast often resembling the shape of a pie wedge d. A small white blister on the tip of the nipple e. Fever and flulike symptoms
ANS: A, B, C, E Feedback Correct These symptoms are commonly associated with mastitis and should be included in the nurse's discussion of mastitis. Incorrect This symptom generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.
1. While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include (Select all that apply.) a. culture. b. anxiety and fear. c. previous experiences with pain. d. intervention of caregivers. e. support systems.
ANS: A, B, C, E Culture: a woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: an anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although this may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps). PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 356 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
A pregnant woman reports that she works in a long-term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine. As the nurse, you are aware that some immunizations are safe to administer during pregnancy, whereas others are not. Which vaccines could this patient receive? Select all that apply. a. Tetanus b. Hepatitis A and B c. Measles, mumps, rubella (MMR) d. Influenza e. Varicella
ANS: A, B, D Feedback Correct Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe to administer for women who have a risk for contracting or developing the disease. Incorrect Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus.
MULTIPLE RESPONSE The nurse who elects to practice in the area of obstetrics often hears discussion regarding the "four Ps." These are the four major factors that interact during normal childbirth. What are the "four Ps"? a. Powers b. Passage c. Position d. Passenger e. Psyche
ANS: A, B, D, E Feedback Correct Powers: the two powers of labor are uterine contractions and pushing efforts. During the first stage of labor through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. Passage: the passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor, because bones and joints do not yield as readily to the forces of labor. Passenger: this is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. Psyche: the psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman's ability to cope. Incorrect Position is not one of the "four Ps."
MULTIPLE RESPONSE Approximately 60% to 80% of women with one low transverse uterine incision from a previous cesarean birth may have a successful vaginal delivery. Recommendations from ACOG related to VBAC risks include (select all that apply) a. Immediate availability of the obstetric provider b. Delivery at a tertiary care center c. Availability of anesthesia personnel d. Personnel who can assist with the cesarean birth e. Use of misoprostol for cervical ripening
ANS: A, C, D Feedback Correct A VBAC delivery should only be attempted with the obstetric provider in house, and anesthesia along with operative personnel readily available to perform a cesarean birth. Incorrect VBAC deliveries may be done in community hospitals if appropriate policies and guidelines for care are in place. Misoprostol administration is contraindicated in a patient with a previous uterine scar.
2. As recently as 2005, the American Academy of Pediatrics revised safe sleep practices to assist in the prevention of sudden infant death syndrome. The nurse should model these practices in hospital and incorporate this information into the teaching for new parents. They include (select all that apply) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. "Tummy time" for play d. Placing the infant's crib in the parents' room e. A soft mattress
ANS: A, C, D Feedback Correct The back to sleep position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the baby's head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. Ideally the infant's crib should be placed in the parents' room. Incorrect The side-sleeping position is no longer an acceptable alternative according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts, sheepskins, etc., should not be placed under the infant.
In some Middle Eastern and African cultures, female genital mutilation is a prerequisite for marriage. Women who now live in North America need care from nurses who are knowledgeable about the procedure and comfortable with the abnormal appearance of her genitalia. When caring for this woman, the nurse can formulate a diagnosis with the understanding that the woman may be at risk for (select all that apply) a. Obstructed labor b. Increased signs of pain response c. Laceration d. Hemorrhage e. Infection
ANS: A, C, D, E Feedback Correct The woman is at risk for all of these complications. Female genital mutilation, cutting, or circumcision involves removal of some or all of the external female genitalia. The labia majora are often stitched together over the vaginal and urethral opening as part of this practice. Enlargement of the vaginal opening may be performed before or during the birth. Incorrect The woman is unlikely to give any verbal or nonverbal signs of pain. This lack of response does not indicate lack of pain. In fact, pelvic examinations are likely to be very painful because the introitus is so small and inelastic scar tissue makes the area especially sensitive. A pediatric speculum may be necessary, and the patient should be made as comfortable as possible.
MULTIPLE RESPONSE 1. Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? Select all that apply. a. Rupture of membranes at or near term b. Convenience of the woman or her physician c. Chorioamnionitis (inflammation of the amniotic sac) d. Postterm pregnancy e. Fetal death
ANS: A, C, D, E Feedback Correct A, C, D, E. These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Incorrect B. Elective inductions for convenience of the woman or her provider are not recommended; however, they have become common. Factors such as rapid labors and living a long distance from a health care facility may be a valid reason in such a circumstance.
3. Hearing loss occurs in 9% of newborns. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (select all that apply) a. To prevent or reduce developmental delay b. Reassurance for concerned new parents c. Early identification and treatment d. To help the child communicate better e. To achieve one of the Healthy People 2020 goals
ANS: A, C, D, E Feedback Correct These are all appropriate reasons for auditory screening of the newborn. Infants who do not pass should be rescreened. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age. Incorrect New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants that are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support.
During pregnancy there are a number of changes that occur as a direct result of the presence of the fetus. Which of these adaptations meet this criteria? Select all that apply. a. Leukorrhea b. Development of the operculum c. Quickening d. Ballottement e. Lightening
ANS: A, C, E Feedback Correct Leukorrhea is a white or slightly gray vaginal discharge that develops in response to cervical stimulation by estrogen and progesterone. Quickening is the first recognition of fetal movements or "feeling life." Quickening is often described as a flutter and is felt earlier in multiparous women than in primiparas. Lightening occurs when the fetus begins to descent into the pelvis. This occurs two weeks before labor in the nullipara and at the start of labor in the multipara. Incorrect Mucous fills the cervical canal creating a plug otherwise known as the operculum. The operculum acts as a barrier against bacterial invasion during the pregnancy. Passive movement of the unengaged fetus is referred to as ballottement.
3. A lactating woman tells the nurse she is glad to no longer have to follow specific dietary recommendations, now that her baby has been born. The nurse responds by teaching her that lactating women have an even greater need for which nutrients? (Select all that apply.) a. Vitamin A b. Vitamin D c. Folic acid d. Iron e. Iodine
ANS: A, E The lactating woman needs more vitamin A and iodine than the pregnant woman. The requirements for vitamin D are the same in both groups. The lactating woman needs less folic acid and iron than a pregnant woman. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: Table 14.3 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
A woman's last menstrual period was June 10. Her estimated date of delivery (EDD) is a. April 7 b. March 17 c. March 27 d. April 17
ANS: B Feedback A April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of adding 7 days. B To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 3 months (March 10), and adds 7 days (March 17). C March is the correct month, but instead of adding 7 days, 17 days were added. D April 17 is subtracting 2 months instead of 3 months.
Mimicry refers to observing and copying the behaviors of other mothers. An example might be a. Babysitting for a neighbor's children b. Wearing maternity clothes before they are needed c. Daydreaming about the newborn d. Imagining oneself as a good mother
ANS: B Feedback A Babysitting other children is a form of role playing where the woman practices the expected role of motherhood. B Wearing maternity clothes before they are needed helps the expectant mother "feel" what it's like to be obviously pregnant. C Daydreaming is a type of fantasy where the woman "tries on" a variety of behaviors in preparation for motherhood. D Imagining herself as a good mother is the woman's effort to look for a good role fit. She observes behavior of other mothers and compares them with her own expectations.
A number of cardiovascular system changes occur during pregnancy. Which finding is considered normal for a woman during pregnancy? a. Cardiac output rises by 25% b. Increased pulse rate c. Increased blood pressure d. Decreased red blood cell (RBC) production
ANS: B Feedback A Cardiac output increases by 50% with half of this rise occurring in the first 8 weeks gestation. B The pulse increases about 15 to 20 beats/min, which persists to term. C In the first trimester, blood pressure usually remains the same as the prepregnancy level, but it gradually decreases up to about 20 weeks of gestation. During the second trimester, both the systolic and diastolic pressures decrease by about 5 to 10 mm Hg. D Production of RBCs accelerates during pregnancy.
Which statement related to changes in the breasts during pregnancy is the most accurate? a. During the early weeks of pregnancy there is decreased sensitivity. b. Nipples and areolae become more pigmented. c. Montgomery tubercles are no longer visible around the nipples. d. Venous congestion of the breasts is more visible in the multiparous woman.
ANS: B Feedback A Fullness, heightened sensitivity, tingling and heaviness of the breasts occur in the early weeks of gestation in response to increased levels of estrogen and progesterone. B Nipples and areolae become more pigmented, and the nipples become more erectile and may express colostrum. C Montgomery tubercles may be seen around the nipples. These sebaceous glands may have a protective role in that they keep the nipples lubricated for breastfeeding. D Venous congestion in the breasts is more obvious in primigravidas.
A patient in her first trimester complains of nausea and vomiting. She asks, "Why does this happen?" The nurse's best response is a. "It is due to an increase in gastric motility." b. "It may be due to changes in hormones." c. "It is related to an increase in glucose levels." d. "It is caused by a decrease in gastric secretions."
ANS: B Feedback A Gastric motility decreases during pregnancy. B Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. C Glucose levels decrease in the first trimester. D Gastric secretions do decrease, but this is not the main cause of nausea and vomiting.
Physiologic anemia often occurs during pregnancy as a result of a. Inadequate intake of iron b. Dilution of hemoglobin concentration c. The fetus establishing iron stores d. Decreased production of erythrocytes
ANS: B Feedback A Inadequate intake of iron may lead to true anemia. B When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. C If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. D There is an increased production of erythrocytes during pregnancy.
The nurse who practices in a prenatal clinic understands that a major concern of lower socioeconomic groups is to a. Maintain group health insurance on their families. b. Meet health needs as they occur. c. Practice preventive health care. d. Maintain an optimistic view of life.
ANS: B Feedback A Lower socioeconomic groups usually do not have group health insurances. B Because of economic uncertainty, lower socioeconomic groups place more emphasis on meeting the needs of the present rather than on future goals. C They may value health care, but cannot afford preventive health care. D They may struggle for basic needs and often do not see a way to improve their situation. It is difficult to maintain optimism.
Early pregnancy classes offered in the first and second trimesters cover a. Phases and stages of labor b. Coping with common discomforts of pregnancy c. Methods of pain relief d. Predelivery and postdelivery care of the patient having a cesarean delivery
ANS: B Feedback A Phases and stages of labor are taught in childbirth preparation classes. B Early pregnancy classes focus on the first two trimesters and cover information on adapting to pregnancy, dealing with early discomforts, and understanding what to expect in the months ahead. C Pain control is part of childbirth preparation classes. D This is taught in cesarean birth preparation classes.
The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to a. Compensate for decreased renal plasma flow. b. Provide adequate perfusion of the placenta. c. Eliminate metabolic wastes of the mother. d. Prevent maternal and fetal dehydration.
ANS: B Feedback A Renal plasma flow increases during pregnancy. B The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. C Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. D This is not the primary reason for the increase in volume.
Which complaint by a patient at 35 weeks of gestation requires additional assessment? a. Shortness of breath when climbing stairs b. Abdominal pain c. Ankle edema in the afternoon d. Backache with prolonged standing
ANS: B Feedback A Shortness of breath is an expected finding by 35 weeks. B Abdominal pain may indicate preterm labor or placental abruption. C Ankle edema in the afternoon is a normal finding at this stage of pregnancy. D Backaches while standing is a normal finding during the later stages of pregnancy.
Which situation best describes a man "trying on" fathering behaviors? a. Spending more time with his siblings b. Coaching a Little League baseball team c. Reading books on newborn care d. Exhibiting physical symptoms related to pregnancy
ANS: B Feedback A The man normally will seek closer ties with his father. B Interacting with children and assuming the behavior and role of a father best describes a man "trying on" being a father. C Men do not normally read information that is provided in advance. The nurse should be prepared to present the information after the baby is born, when it is more relevant. D This is called couvade.
Which finding in the urine analysis of a pregnant woman is considered a variation of normal? a. Proteinuria b. Glycosuria c. Bacteria in the urine d. Ketones in the urine
ANS: B Feedback A The presence of protein could indicate kidney disease or preeclampsia. B Small amounts of glucose may indicate "physiologic spilling." C Urinary tract infections are associated with bacteria in the urine. D An increase in ketones indicates that the patient is exercising too strenuously or has an inadequate fluid and food intake.
During the active phase of labor, the FHR of a low-risk patient should be assessed every a. 15 minutes b. 30 minutes c. 45 minutes d. 1 hour
ANS: B Feedback A 15-minute assessments are appropriate for a fetus at high risk. B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. C 45-minute assessments during the active phase of labor is not frequent enough to monitor for complications. D 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.
To adequately teach patients about the process of labor, the nurse knows that which event is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes
ANS: B Feedback A Bloody show can occur before true labor. B The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. C Fetal descent can occur before true labor. D False labor may have contractions that occur this frequently, but it is usually inconsistent.
The primary difference between the labor of a nullipara and that of a multipara is the a. Amount of cervical dilation b. Total duration of labor c. Level of pain experienced d. Sequence of labor mechanisms
ANS: B Feedback A Cervical dilation is the same for all labors. B Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. C Level of pain is individual to the woman, not to the number of labors she has experienced. D The sequence of labor mechanisms is the same with all labors.
A 25-year-old primigravida is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly the woman pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely a. Normal and related to hyperventilation b. Common during the transition phase of labor c. A sign that she needs analgesia d. Indicative of abnormal labor
ANS: B Feedback A Hyperventilation will produce signs of respiratory alkalosis. B The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. C If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. D This change of behavior is an expected occurrence during the transition phase.
Which statement is the best rationale for assessing maternal vital signs between contractions? a. During a contraction, assessing fetal heart rates is the priority. b. Maternal circulating blood volume increases temporarily during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate.
ANS: B Feedback A It is important to monitor fetal response to contractions, but the question is concerned with the maternal vital signs. B During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows pulse. C Maternal blood flow is increased during a contraction. D Vital signs are altered by contractions but are considered accurate for that period of time.
An indication for an episiotomy would be a woman who a. Has a routine vaginal birth b. Has fetal shoulder dystocia c. Is delivering a preterm infant d. Has a history of rapid deliveries
ANS: B Feedback A Once routine for all vaginal deliveries, the perceived benefits of reducing pain and perineal tearing have not proven true. B An episiotomy is indicated in the situation where the shoulder of the fetus become lodged under the mother symphysis during birth. C A preterm infant is smaller and does not need as much space for delivery. D Rapid deliveries are not an indication for a mediolateral episiotomy.
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately? a. A woman in active labor with contractions every 31 minutes lasting 60 seconds each b. A woman in transition with contractions every 2 minutes lasting 90 seconds each c. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each d. A woman in early labor with contractions every 5 minutes lasting 40 seconds each
ANS: B Feedback A Oxytocin may assist this woman's contractions to become closer and more efficient. B This woman's contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. C There is an appropriate resting period between this woman's contractions. D There is an appropriate resting period between this woman's contractions for her stage of labor.
If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to a. Take the blood pressure. b. Massage the fundus. c. Notify the physician or nurse-midwife. d. Place the woman in Trendelenburg position.
ANS: B Feedback A The blood pressure is an important assessment to determine the extent of blood loss, but it is not the top priority. B The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. C Notification should occur after all nursing measures have been attempted with no favorable results. D Trendelenburg position is contraindicated for this woman at this point. This position does not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.
When positioning the Foley catheter before cesarean birth, the nurse knows that the catheter drainage tube and catheter bag should be a. Positioned on top of the patient's leg b. Placed near the head of the table c. Clamped during the cesarean section d. Positioned at the foot of the surgeon under the sterile drapes
ANS: B Feedback A The drain tube of the catheter should be positioned under her leg to promote drainage and to keep the catheter away from the operative area. B The anesthesia clinician must monitor urine output during the surgery. C Urinary output must be continuously monitored. An early sign of hypovolemia is a decreasing urinary output. D The surgeon might step on the drainage bag if the catheter was below the drapes, and no one could monitor the urine output.
It is important for the nurse providing care during labor to be aware that pregnant women can usually tolerate the normal blood loss associated with childbirth because they have a. A higher hematocrit b. Increased blood volume c. A lower fibrinogen level d. Increased leukocytes
ANS: B Feedback A The hematocrit decreases with pregnancy due to the high fluid volume. B Women have a significant increase in blood volume during pregnancy. After delivery, the additional circulating volume is no longer necessary. C Fibrinogen levels increase with pregnancy. D Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss.
A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage
ANS: B Feedback A The latent phase is from the beginning of true labor until 3 cm of cervical dilation. B The active phase of labor is characterized by cervical dilation of 4 to 7 cm. C The second stage of labor begins when the cervix is completely dilated until the birth of the baby. D The third stage of labor is from the birth of the baby until the expulsion of the placenta.
After a forceps-assisted birth, the mother is observed to have continuous bright red lochia but a firm fundus. What other data indicates the presence of a potential vaginal wall hematoma? a. Mild, intermittent perineal pain b. Edema and discoloration of the labia and perineum c. Lack of an episiotomy d. Lack of pain in the perineal area
ANS: B Feedback A The pain with vaginal hematoma is severe and constant. B The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. C An episiotomy is performed as the fetal head distends the perineum. D The pain associated with vaginal hematoma is severe.
Which event indicates a complication of an external version? a. Maternal pulse rate of 100 bpm b. Fetal bradycardia persisting 10 minutes after the version c. Fetus returning to the original position d. Increased maternal anxiety after the version
ANS: B Feedback A There are few risks to the woman during an external version. B Fetal bradycardia after a version may indicate that the umbilical cord has become compressed, and the fetus is having hypoxia. C The fetus may return to the original position, but this is not a complication of the version. D Anxiety may occur before the version but should decrease after the procedure is completed.
What is an appropriate response to a woman's comment that she is worried about having a cesarean birth? a. "Don't worry. Everything will be okay." b. "What are your feelings about having a cesarean birth?" c. "I know you're worried, but this is a routine procedure." d. "Patients commonly worry about surgery."
ANS: B Feedback A This answer is stating that the patient's feelings are not important. B Allowing the patient to express her feelings is the most appropriate nursing response. The nurse should never provide the patient with false reassurance or disregard her feelings. C This is belittling the patient's concerns and does not allow her to express her concerns. D This answer is close ended and belittling to the patient's feelings.
A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are a. Contraction pattern, amount of discomfort, and pregnancy history b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth c. Identification of ruptured membranes, the woman's gravida and para, and her support person d. Last food intake, when labor began, and cultural practices the couple desires
ANS: B Feedback A This is an important nursing assessment, but does not take priority if the birth is imminent. B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. C This is an assessment that can occur later in the admission process if time permits. D This part of the assessment can occur later in the admission process if time permits.
To assess the duration of labor contractions, the nurse determines the time a. From the beginning of one contraction to the beginning of the next b. From the beginning to the end of each contraction c. Of the strongest intensity of each contraction d. Of uterine relaxation between two contractions
ANS: B Feedback A This is the frequency of the contractions. B Duration of labor contractions is the average length of contractions from beginning to end. C This is the strength or intensity of the contractions. D This is the interval of the contraction phase.
The nurse knows that a urinary catheter is added to the instrument table if a forceps-assisted birth is anticipated. What is the correct rationale for this intervention? a. Spontaneous release of urine might contaminate the sterile field. b. An empty bladder provides more room in the pelvis. c. A sterile urine specimen is needed preoperatively. d. A Foley catheter prevents the membranes from spontaneously rupturing.
ANS: B Feedback A Urine is sterile. B Catheterization provides room for the application of the forceps blades and limits bladder trauma. C A clean-catch urinalysis is usually sufficient for preoperative treatment. D The membranes must be ruptured and the cervix completely dilated for a forceps-assisted birth.
A maternal indication for the use of vacuum extraction is a. A wide pelvic outlet b. Maternal exhaustion c. A history of rapid deliveries d. Failure to progress past 0 station
ANS: B Feedback A With a wide pelvic outlet, vacuum extraction is not necessary. B With a mother who is exhausted will be unable to assist with the expulsion of the fetus. C With a rapid delivery, vacuum extraction is not necessary. D A station of 0 is too high for a vacuum extraction.
20. An important independent nursing action to promote normal progress in labor is a. Assessing the fetus b. Encouraging urination about every 1 to 2 hours c. Limiting contact with the woman's partner d. Regulating intravenous fluids
ANS: B Feedback A Assessment of the fetus is an important task, but will not promote normal progression of labor. B The bladder can reduce room in the woman's pelvis that is needed for fetal descent and can increase her discomfort. C The woman needs her support system during labor, and contact should not be limited. D Maintaining hydration is an important task, but it will not promote normal progression of labor.
21. The nurse should explain to new parents that the most serious consequence of propping an infant's bottle is a. Dental caries b. Aspiration c. Ear infections d. Colic
ANS: B Feedback A Dental caries become a problem when milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. B Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. C Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs. However, this is not the most serious consequence. D Colic can occur, but it is not the most serious consequence.
7. The hormone necessary for milk production is a. Estrogen b. Prolactin c. Progesterone d. Lactogen
ANS: B Feedback A Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. C Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. D Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.
11. Why is adequate hydration important when uterine activity occurs before pregnancy is at term? a. Fluid and electrolyte imbalance can interfere with the activity of the uterine pacemakers. b. Dehydration may contribute to uterine irritability for some women. c. Dehydration decreases circulating blood volume, which leads to uterine ischemia. d. Fluid needs are increased because of increased metabolic activity occurring during contractions.
ANS: B Feedback A Fluid and electrolyte imbalances are not associated with preterm labor. B Intravenous fluids are ordered according to their expected benefit. Adequate hydration promotes urination and decreased risk for infection. C The woman has an increase blood volume during pregnancy. D Fluid needs do not increase due to contractions.
7. To prevent the kidnapping of newborns from the hospital, the nurse should a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. Question anyone who is seen walking in the hallways carrying an infant. c. Allow no visitors in the maternity area except those who have identification bracelets. d. Restrict the amount of time infants are out of the nursery.
ANS: B Feedback A It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit. B Infants should be transported in the hallways only in their cribs. C This will be difficult to monitor and will limit the mother's support system from visiting. D Infants need to spend time with the parents to facilitate the bonding process.
24. Rupture of the amniotic sac before the onset of true labor, regardless of length of gestation is called premature rupture of membranes (PROM). The first priority for the nurse is to determine whether membranes are truly ruptured. Other explanations for this increase in fluid discharge include all except a. Urinary incontinence b. Leaking of amniotic fluid c. Loss of mucous plug d. An increase in vaginal discharge
ANS: B Feedback A It is not uncommon for patients to mistake urinary incontinence for leakage of amniotic fluid. B Leaking of amniotic fluid is an indication of PROM. C Loss of the mucous plug can lead a woman to believe that her membranes have ruptured when they have not. D Late in pregnancy there may be an increase in vaginal discharge. This may be mistaken for rupture of membranes.
13. An unfortunate but essential role of the nurse is protecting the infant from abduction. Which statement regarding the profile of a potential abductor is the most accurate? a. Male gender b. A young woman who has had a previous pregnancy loss c. A middle-aged woman past childbearing age d. A female with a number of children of her own
ANS: B Feedback A Newborns are usually abducted by women who are familiar with the birth facility and its routines. B The woman is usually of childbearing age and may have had a previous pregnancy loss or has been unable to have a child of her own. She may want an infant to solidify the relationship with her husband or boyfriend and may have pretended to be pregnant. C Infant abductors are women of childbearing age, often overweight, who may live near the birth facility. D A woman who already has children of her own does not fit the profile of a potential abductor.
5. The nurse's initial action when caring for an infant with a slightly decreased temperature is to a. Notify the physician immediately. b. Place a cap on the infant's head and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula, as this is a sign of formula intolerance.
ANS: B Feedback A Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. B A cap will prevent further heat loss from the head, and having the mother place the infant skin-to-skin should increase the infant's temperature. C A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. D Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.
2. A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c. Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. Prevent the infant's eyelids from sticking together and help the infant see.
ANS: B Feedback A Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. B This is an accurate explanation. C Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. It is instilled to prevent gonorrheal or chlamydial infection. D Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.
2. A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for at-home continuation of the tocolytic effect? a. Ritodrine b. Terbutaline c. Calcium gluconate d. Magnesium sulfate
ANS: B Feedback A Ritodrine is the only drug approved by the FDA for tocolysis; however, it is rarely used because of significant side effects. B The woman receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. C Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. D Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.
18. In order to prevent nipple trauma, the nurse should teach the new mother to a. Limit the feeding time to less than 5 minutes. b. Position the infant so the nipple is far back in the mouth. c. Assess the nipples before each feeding. d. Wash the nipples daily with mild soap and water.
ANS: B Feedback A Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. B If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. C Assessing the nipples for trauma is important, but it will not prevent sore nipples. D Soap can be drying to the nipples and should be avoided during breastfeeding.
24. What information about iron supplementation should the nurse teach a new mother? a. Start iron supplementation shortly after birth if the infant is breastfeeding exclusively. b. Iron-fortified formula will meet the infant's iron requirements. c. Iron supplements must be given when the infant begins teething. d. Infants need a multivitamin with iron every day.
ANS: B Feedback A Term infants who are exclusively breastfed have adequate iron stored until they are age 6 months. B Iron-fortified formula will meet the infant's initial iron requirements. Solid foods added to the diet maintain iron needs as formula intake decreases. C Iron supplements are not necessary for adequate teething. D Vitamins and minerals are added to processed formulas and cereals. It should not be necessary for the child to receive a multivitamin with iron unless the infant is at risk for undernutrition.
1. The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth. Which suggestion by the nurse is most appropriate? a. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infant's mouth. c. A popping sound occurs when the breast is correctly removed from the infant's mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.
ANS: B Feedback A The infant who is sleeping may lose grasp on the nipple and areola, resulting in "chewing" on the nipple, making it sore. B Inserting a finger into the corner of the baby's mouth between the gums to break the suction avoids trauma to the breast. C A popping sound indicates improper removal of the breast from the baby's mouth and may cause cracks or fissures in the breast. D Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.
15. A new mother is concerned because her 1-day-old newborn is taking only 1 ounce at each feeding. The nurse should explain that the a. Infant does not require as much formula in the first few days of life. b. Infant's stomach capacity is small at birth but will expand within a few days. c. Infant tires easily during the first few days but will gradually take more formula. d. Infant is probably having difficulty adjusting to the formula.
ANS: B Feedback A The infant's requirements are the same, but the stomach capacity needs to increase before taking in adequate amounts. B The infant's stomach capacity at birth is 10 to 20 mL and increases to 60 to 90 mL by the end of the first week. C The infant's sleep patterns do change, but the infant should be awake enough to feed. D There are other symptoms that occur if there is a formula intolerance.
12. To prevent breast engorgement, the new breastfeeding mother should be instructed to a. Apply cold packs to the breast before feeding. b. Breastfeed frequently and for adequate lengths of time. c. Limit her intake of fluids for the first few days. d. Feed her infant no more than every 4 hours.
ANS: B Feedback A Warm packs should be applied to the breast before feedings. B Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. C Fluid intake should not be limited with a breastfeeding mother; that will decrease the amount of breast milk produced. D Breast milk moves through the stomach within 1.5 to 2 hours, so waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and to establish lactation.
4. A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. Based on this information, this woman should feed her infant about every 2.5 to 3 hours when she a. Waves her arms in the air b. Makes sucking motions c. Has hiccups d. Stretches out her legs straight
ANS: B Feedback A Waving about her arms in the air is not a feeding readiness cue. B Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. C Hiccups are not a typical feeding-readiness cue. D Stretching out her extremities is not a typical feeding-readiness cue.
8. The nurse is assisting a normally active pregnant woman in developing a meal plan. Before she got pregnant, she ate 1800 calories a day. How many calories does she need now? a. 2000 b. 2140 c. 2342 d. 2400
ANS: B A woman should increase her daily caloric intake by 340 calories during the second trimester, so this woman needs 2140 daily calories. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 14.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The results of a nonstress test shows three fetal heart rate accelerations with fetal movement that peak at 15 beats per minute above baseline and last 15 seconds. The nurses next action should be to A. Apply acoustic stimulation for one second for further testing B. This is a reassuring sign and no other testing is necessary at this time C. Continue to test for 40 additional minutes D. Prepare the woman for a contraction stress test
ANS: B A. Acoustic stimulation can be used if the fetus is not active. The results given in the base of the question are reassuring, and no other testing is necessary. B. A reactive sign is at least two fetal heart rate accelerations with or without fetal movement, occurring within a 20-minute period, peaking at least 15 beats per minute about the baseline, and lasting 15 seconds. This is reassuring, and no further testing is necessary. C. The test results are reassuring, and there is no need to continue the test. D. The test results are reassuring, and no further testing is necessary at this time.
The purpose of initiating contractions in a contraction stress test is to A. Determine the degree of fetal activity B. Apply a stressful stimulus to the fetus C. Identify fetal acceleration patterns D. Increase placental blood flow
ANS: B A. The contraction stress test involves recording the response of the fetal heart rate to stress induced by uterine contractions. B. The contraction stress test involves recording the response of the fetal heart rate to stress induced by uterine contractions. C. The contraction stress test involves recording the response of the fetal heart rate to stress induced by uterine contractions. D. The contraction stress test involves recording the response of the fetal heart rate to stress induced by uterine contractions.
A woman who is 6 weeks' pregnant is scheduled for an ultrasound. She asks the nurse what can be seen at this stage of the pregnant. The nurse would be correct if she responded: A. The sex of the baby B. The baby's heartbeat C. Characteristics of the baby's face D. Fetal presentation
ANS: B A. The sex of the baby cannot be determined until about 12 weeks. B. The heartbeat is visible when the embryo is 5 mm in length. Fetal sex and details about the baby cannot be seen until later in the pregnancy. C. Characteristics of the baby's face can be seen on a three-dimensional sonogram later in the pregnancy. D. Fetal presentation is determined during the second and third trimester
15. In teaching the pregnant adolescent about nutrition, what suggestion by the nurse is best? a. Eliminate common teen snack foods, because they are too high in fat and sodium. b. Work with the teen to include some fast food in a healthy prenatal diet. c. Suggest that she not eat at fast-food restaurants where the foods are of poor nutritional value. d. Realize that most adolescents are unwilling to make dietary changes during pregnancy.
ANS: B Adolescents have some special nutritional needs during pregnancy, but they also need to feel that they fit in with their peers. Working with the teen to develop a healthy diet while including some snack and fast foods has the best chance of providing good nutrition. Telling the teen to eliminate certain foods or restaurants is likely not to work. Including the teen will make her more willing to make dietary changes. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 265 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
12. Which pregnant adolescent is most at risk for a nutritional deficit during pregnancy? a. A 15-year-old of normal height and weight b. A 17-year-old who is 10 pounds underweight c. A 16-year-old who is 10 pounds overweight d. A 16-year-old of normal height and weight
ANS: B All adolescents are at nutritional risk during pregnancy, but the adolescent who is pregnant and underweight is most at risk, because she is already deficient in nutrition and must now supply the nutritional intake for both herself and her fetus. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 265 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
25. Which patient is most likely to experience pain during labor? a. Gravida 2 who has not attended childbirth preparation classes b. Gravida 2 who is anxious because her last labor was difficult c. Gravida 1 whose fetus is in a breech presentation d. Gravida 3 who is using Lamaze breathing techniques
ANS: B Anxiety affects a woman's perception of pain. Tension during labor causes tightening of abdominal muscles, impeding contractions and increasing pain by stimulation of nerve endings. The gravida 2 has previous experience, and this will decrease anxiety. This woman will have more pain than if the infant is in vertex. Also, there is an increased likelihood that she will have a cesarean section and not go through labor. The gravida 3 has previous experience and has prepared herself for the labor. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 356 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
23. A nurse teaching a prenatal class is discussing nutrition. What foods does the nurse advise pregnant women to avoid? a. Canned white tuna as a preferred choice b. Shark, swordfish, and mackerel c. Treating fish caught in local waterways as the safest d. High levels of mercury in salmon and shrimp
ANS: B As a precaution against ingesting too much mercury, the pregnant patient should avoid eating all of these as well as the less common tilefish. Six ounces a week of canned albacore tuna is acceptable. Pregnant women should check with local authorities on the safety of eating locally caught fish, but if no advisories are in effect, eating them is fine. Salmon and shrimp are fine too up to 12 ounces a week. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 263 | Safety Alert Box OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
24. Plantar creases should be evaluated within a few hours of birth because a. the newborn has to be footprinted. b. as the skin dries, the creases will become more prominent. c. heel sticks may be required. d. creases will be less prominent after 24 hours.
ANS: B As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting will not interfere with the creases. Heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 454 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
23. A new nurse notes a fetal heart rate pattern of late deceleration with minimal variability in a laboring woman with vaginal bleeding. Which action by the new nurse warrants intervention by the charge nurse? a. Assesses maternal blood pressure b. Assesses for a prolapsed cord c. Prepares to administer terbutaline d. Discontinues oxytocin
ANS: B Assessing for a prolapsed cord requires a vaginal examination, which is contraindicated when the woman has active vaginal bleeding. The other actions are appropriate. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 344 | Safety Alert Box OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
20. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Ortolani's sign b. Asymmetric thigh and gluteal creases c. Negative Barlow test d. Equal knee heights
ANS: B Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. Positive Ortolani's sign yields a "clunking" sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum. If the hip is dislocated, the knee on the affected side will be lower. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 444 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
14. A patient who is in week 28 of gestation is concerned about her weight gain of 1 pound in 1 week. Which response by the nurse is best? a. "You should try to decrease your amount of weight gain for the next 12 weeks." b. "You have gained an appropriate amount for the number of weeks of your pregnancy." c. "You should not gain any more weight until you reach the third trimester." d. "You have not gained enough weight for the number of weeks of your pregnancy."
ANS: B At 28 weeks, a weight gain of 1 pound in 1 week is within the recommended range of 0.8 to 1 pound per week. The woman should be reassured that this is normal and healthy. The other responses are inaccurate. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 256 | Table 14.1 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
6. The nurse working with a pregnant woman explains that a major advantage of nonpharmacologic pain management is that a. more complete pain relief is possible. b. no side effects or risks to the fetus are involved. c. the woman remains fully alert at all times. d. a more rapid labor is likely.
ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The woman's alertness is not altered by medication, but the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 356 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
22. Infants in whom cephalhematomas develop are at increased risk for a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.
ANS: B Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infection, caput, or erythema toxicum. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 451 | Box 21.5 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. The nurse caring for women in labor understands that childbirth pain is different from other types of pain in that it is a. more responsive to pharmacologic management. b. associated with a physiologic process. c. designed to make one withdraw from the stimulus. d. less intense.
ANS: B Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not more or less responsive to medication. The pain with childbirth is a normal process; it is not caused by the type of injury when withdrawal from the stimuli is seen. Childbirth pain is not less intense than other types of pain. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 354 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
15. The student nurse learns that the process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. enterohepatic circuit. b. conjugation of bilirubin. c. unconjugation of bilirubin. d. albumin binding.
ANS: B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. The enterohepatic circuit is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat soluble. Albumin binding is to attach something to a protein molecule. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 431 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
9. A pregnant woman in the perinatal clinic is a recovering anorexic. She is distressed at the emphasis on weight gain. The nurse explains that the most important reason for evaluating the pattern of weight gain in pregnancy is to a. prevent excessive adipose tissue deposits. b. identify potential nutritional problems or complications of pregnancy. c. assess if this woman has relapsed. d. determine cultural influences on the woman's diet.
ANS: B Deviations from the recommended pattern of weight gain may indicate nutritional problems or developing complications. The nurse should assure this patient that monitoring weight gain is a routine part of prenatal care to ensure the baby's well-being. Preventing adipose tissue deposits is not the reason for monitoring weight gain. Determining cultural influences on diet and weight gain is important but not the most important reason. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 255 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
6. A student nurse is preparing to administer misoprostol (Cytotec). What action by the student seen by the registered nurse demonstrates adequate knowledge about this medication? a. Assesses maternal blood pressure 30 minutes after administration b. Assesses fetal heart tones prior to administering the medication c. Documents the drug administration in the woman's chart d. Takes and records an apical pulse for 1 minute prior to administration
ANS: B Fetal heart tones should be assessed prior to giving cervical ripening agents such as misoprostol. It is not necessary to assess maternal blood pressure afterward or an apical pulse prior to administering the medication. Documentation of all medications is a legal requirement but is not related specifically to this drug. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: Box 17.2 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity
27. A woman is experiencing most of her labor pain in her back. What action by the nurse is best? a. Positioning the woman lying supine with head slightly elevated b. Showing the support person how to apply firm pressure to the sacrum c. Assisting the woman to sit upright with the legs straight d. Massaging her upper back during a contraction
ANS: B Firm pressure against the sacrum may be helpful in relieving the discomfort associated with back labor. The nurse can provide this action, but including the support person (if desired) is beneficial. The woman should not lie on her back. Sitting up with legs straight would put more pressure onto the lower back area. The massage should be in the lower back where the pain is located. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 358 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
33. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what types of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at bright stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."
ANS: B Infants can track their parents' faces, including eyes and prefer to look at complex patterns. Newborns seem to have clearest visual acuity at about 19 cm. Infants prefer complex patterns, regardless of color and also prefer low lighting. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 445 | p. 448 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
16. The registered nurse explains to the student that when giving a narcotic to a laboring woman, the nurse should inject the medication at the beginning of a contraction so that a. full benefit of the medication is received during that contraction. b. less medication will be transferred to the fetus. c. the medication will be rapidly circulated. d. the maternal vital signs will not be adversely affected.
ANS: B Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. The full benefit will be received by the woman; however, it will decrease the amount reaching the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 367 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
7. A woman has a history of hypertension during pregnancy. What method of intrapartum fetal monitoring does the nurse initiate? a. Continuous auscultation with a fetoscope b. Continuous electronic fetal monitoring c. Intermittent assessment with a Doppler transducer d. Intermittent electronic fetal monitoring for 15 minutes each hour
ANS: B Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 333 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
18. Which statement made by a lactating woman leads the nurse to believe that the woman might have lactose intolerance? a. "I always have heartburn after I drink milk." b. "If I drink more than a cup of milk, I get abdominal cramps and bloating." c. "Drinking milk usually makes me break out in hives." d. "Sometimes I notice that I have bad breath after I drink a cup of milk."
ANS: B One problem that can interfere with milk consumption is lactose intolerance, which is the inability to digest milk sugar because of a lack of the enzyme lactose in the small intestine. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people, although many lactose-intolerant individuals can tolerate small amounts of milk without symptoms. The woman with lactose intolerance is more likely to experience bloating and cramping, not heartburn. A woman who breaks out in hives after consuming milk is more likely to have a milk allergy. Bad breath is not a sign of lactose intolerance. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 266 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
24. When instructing the woman in early labor, the nurse teaches her that an important aspect of proper breathing technique is a. breathing no more than three times the normal rate. b. beginning and ending with a cleansing breath. c. holding the breath no longer than 10 seconds. d. adhering exactly to the techniques as they were taught.
ANS: B The cleansing breath helps the woman clear her mind to focus on relaxing and signals the coach that the contraction is beginning or ending. It is important to prevent hyperventilation; however, the cleansing breaths are the most important aspect of the breathing techniques. The woman should hold her breath for no more than 6 to 8 seconds. The woman needs to be flexible and change her breathing techniques as needed to keep her comfortable. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 359 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Psychosocial Integrity
2. After giving birth the nurse suggests that the woman place the infant to her breast within 15 minutes. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the a. transition period. b. first period of reactivity. c. organizational stage. d. second period of reactivity.
ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 435 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
35. A nurse assesses a newborn's lab values and notes a WBC of 31,000 mm3. What action by the nurse is best? a. Take a set of vital signs and notify the provider. b. Document the findings in the infant's chart. c. Follow unit protocol to initiate a sepsis workup. d. Perform a heel stick for a bedside blood glucose reading.
ANS: B The leukocyte (white blood cell [WBC]) count at birth is 9100 to 34,000/mm3. This is a normal finding so the only action required is to document these results. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 430 OBJ: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance
26. A new mother asks, "Why are you doing a gestational age assessment on my baby? I delivered on time." The nurse's best response is a. "This must be done to meet insurance requirements." b. "It helps us identify infants who are at risk for any problems." c. "The gestational age determines how long the infant will be hospitalized." d. "It was ordered by your doctor."
ANS: B The nurse should provide the mother with accurate information about various procedures performed on the newborn. A gestational age assessment helps identify at-risk infants. It is not done for insurance requirements or to determine hospital days. Assessing gestational age is a nursing assessment and does not have to be ordered. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 454 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
8. Why is continuous electronic fetal monitoring usually used when oxytocin is administered? a. The mother may become hypotensive. b. Uteroplacental exchange may be compromised. c. Maternal fluid volume deficit may occur. d. Fetal chemoreceptors are stimulated.
ANS: B The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This response reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk. Oxytocin affects the uterine muscles. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 333 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
25. The woman in her third trimester asks the nurse how fast she will lose weight after giving birth. What information from the nurse is most accurate? a. You will lose about 20 pounds immediately. b. By the end of 2 weeks after birth you will have lost about 21 pounds. c. You can go on a diet after your first postnatal checkup. d. Most women do not lose all the weight they gain during pregnancy.
ANS: B The woman can expect to lose 12 pounds immediately after birth and another 9 pounds by the end of the 2nd week, putting her total weight loss at that time around 21 pounds. The woman should wait 3 weeks before going on a diet. Most women lose all but a pound or two after childbirth, but this statement is discouraging to the patient. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 269 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
39. A nurse assesses a newborn and finds him to be jittery with a poor suck reflex. What action by the nurse takes priority? a. Ensure the warmer is set to the correct temperature. b. Obtain a heel stick for bedside glucose reading. c. Listen to the newborn's heart and lungs. d. Perform a gestational age assessment.
ANS: B These are signs of possible hypoglycemia. The nurse should obtain blood for a glucose determination. Ensuring the warmer is set correctly and further assessing the baby are appropriate but not related to these findings. There would be no need to repeat the gestational age assessment. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 449 | Safety Alert Box OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
4. Four women are admitted to Labor and Delivery. Which woman met the goal for a healthy weight gain in pregnancy? a. 17 years old, 52 tall, initial weight 116 pounds, today's weight 120 pounds b. 22 years old, 52 tall, initial weight 230 pounds, today's weight 245 pounds c. 24 years old, 53 tall, initial weight 135, today's weight 182 pounds d. 27 years old, 56 tall, initial weight 112 pounds, today's weight 135 pounds
ANS: B This woman was obese at the start of her pregnancy, so a weight gain of 11 to 20 pounds has met the goal (245 230 = 15). Adolescents need to gain enough weight to support both their needs and those of the fetus, so they should gain the recommended amount for normal weight women, so this teen should weigh between 127 and 136, so she clearly did not gain enough weight. The woman who weighed a healthy 135 pounds should not weigh more than 170 pounds, so this woman gained more weight than recommended. The woman who was 56 tall was underweight at conception, so she needed to gain 28 to 40 pounds, which would put her minimum acceptable weight at delivery at 140. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing REF: Table 14.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
29. A nurse admits a woman to the labor and delivery unit who has a history of IV drug abuse. In planning care for this patient, the nurse explains to the student that which pain control plan is contraindicated for this woman? a. Epidural anesthesia b. Bolus administration of butorphanol (Stadol) c. Promethazine (Phenergan) for opioid-induced nausea d. Naloxone (Narcan) if needed for respiratory depression
ANS: B Women who are opiate-dependent should not receive analgesics having mixed agonist and antagonist actions (butorphanol and nalbuphine). Epidural anesthesia not using these drugs is appropriate as are promethazine and naloxone if needed. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Table 18.2 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
2. The nurse explains to parents that which organs are nonfunctional during fetal life? (Select all that apply.) a. Kidneys b. Lungs c. Liver d. Gastrointestinal system e. Adrenal glands
ANS: B, C Most of the fetal blood flow bypasses the nonfunctional lungs and liver. The other organs are functional during fetal life. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 426 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
1. The causes of preterm labor are not fully understood although many factors have been associated with early labor. These include (select all that apply) a. Singleton pregnancy b. History of cone biopsy c. Smoking d. Short cervical length e. Higher level of education
ANS: B, C, D Feedback Correct A history of cone biopsy, smoking, and short cervical length are maternal risk factors for preterm labor. Others include chronic illness, DES exposure as a fetus, uterine abnormalities, obesity, previous preterm labor or birth, number of embryos implanted, preeclampsia, anemia, or infection. Incorrect Uterine distention caused by multifetal pregnancy or hydramnios are risk factors for preterm labor. Low educational level, low socioeconomic status, little or no prenatal care, poor nutrition, or non-white ethnicity are all demographic risk factors for preterm labor and birth.
1. Late in pregnancy, the woman's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include (select all that apply) a. Everted nipples b. Flat nipples c. Inverted nipples d. Nipples that contract when compressed e. Cracked nipples
ANS: B, C, D Feedback Correct Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infant's mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells is debated. A breast pump can be used to draw the nipples out before feedings after delivery. Incorrect Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latch. The infant should be repositioned during feeding. Application of colostrum and breast milk after feedings will aid in healing.
1. What are modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination
ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 427 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
1. A Labor and Delivery nurse knows that four of the five fetal factors that interact to regulate the heart rate are which of the following? (Select all that apply.) a. Uterine activity b. Autonomic nervous system c. Baroreceptors d. Chemoreceptors e. Adrenal glands
ANS: B, C, D, E The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, while parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and the aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing an acceleration in FHR. Uterine activity is a maternal factor. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 333 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
1. The nurse working with pregnant women understands that anorexia and bulimia are associated with which conditions in the newborn? (Select all that apply.) a. Food cravings b. Low birth weight c. Food aversions d. Electrolyte imbalance e. Small for gestational age infants
ANS: B, D, E These conditions are associated with electrolyte imbalance, low birth weight, and small for gestational age infants. All women should be asked about eating disorders, and nurses should watch for behaviors that may indicate disordered eating. Some women eat normally during pregnancy for the sake of the fetus, but others continue their previous dysfunctional eating patterns during pregnancy or in the early postpartum period. Food cravings and aversions are normal for most women during pregnancy. Women may have a strong preference or strong dislike for certain foods. They're generally not harmful, and some, like aversion to alcohol, may be beneficial. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 267 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. A new nurse to Labor and Delivery learns about the three categories of fetal heart rate patterns. Which characteristics of the fetal heart belong in Category III? (Select all that apply.) a. Baseline rate of 110 to 160 bpm b. Tachycardia c. Absent baseline variability NOT accompanied by recurrent decelerations d. Variable decelerations with other characteristics such as shoulders or overshoots e. Absent baseline variability with recurrent variable decelerations f. Bradycardia
ANS: B, D, E, F These characteristics are all considered non-reassuring or abnormal and belong in Category III. A fetal heart rate of 110 to 160 bpm is considered normal and belongs in Category I. Absent baseline variability not accompanied by recurrent decelerations is a Category II characteristic. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 344 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
A woman is currently pregnant; she has a 5-year-old son and a 3-year-old daughter. She had one other pregnancy that terminated at 8 weeks. Her gravida and para are a. Gravida 3 para 2 b. Gravida 4 para 3 c. Gravida 4 para 2 d. Gravida 3 para 3
ANS: C Feedback A Because she is currently pregnant, she is classified as a gravida 4; the pregnancy that was terminated at 8 weeks is classified as an abortion. B Gravida 4 is correct, but she is a para 2. The pregnancy that was terminated at 8 weeks is classified as an abortion. C She has had four pregnancies, including the current one (gravida 4). She had two pregnancies that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion. D Since she is currently pregnant, she is classified as a gravida 4, not a 3. The para is correct.
As a nurse in labor and delivery, you are caring for a Muslim woman during the active phase of labor. You note that when you touch her, she quickly draws away. You should a. Continue to touch her as much as you need to while providing care. b. Assume that she doesn't like you and decrease your time with. c. Limit touching to a minimum, as this may not be acceptable in her culture. d. Ask the charge nurse to reassign you to another patient.
ANS: C Feedback A By continuing to touch her, the nurse is showing disrespect for her cultural beliefs. B A Muslim's response to touch does not reflect like or dislike. C Touching is an important component of communication in various cultures, but if the patient appears to find it offensive, the nurse should respect her cultural beliefs and limit touching her. D This reaction may be offensive to the patient.
A 36-year-old divorcee with a successful modeling career finds out that her 18-year-old married daughter is expecting her first child. What is a major factor in determining how the woman will respond to becoming a grandmother? a. Her career b. Being divorced c. Her age d. Age of the daughter
ANS: C Feedback A Career responsibilities may have demands that make the grandparents not as accessible, but it is not a major factor in determining the woman's response to becoming a grandmother. B Being divorced is not a major factor that determines adaptation of grandparents. C Age is a major factor in determining the emotional response of prospective grandparents. Young grandparents may not be happy with the stereotype of grandparents as being old. D The age of the daughter is not a major factor that determines adaptation of grandparents. The age of the grandparent is a major factor.
Alterations in hormonal balance and mechanical stretching are responsible for several changes in the integumentary system during pregnancy. Stretch marks often occur on the abdomen and breasts. These are referred to as a. Chloasma b. Linea nigra c. Striae gravidarum d. Angiomas
ANS: C Feedback A Chloasma is a facial melasma also known as the "mask of pregnancy." This condition is manifested by a blotchy, hyperpigmentation of the skin over the cheeks, nose and forehead especially in dark complexioned women. B Linea nigra is a pigmented line extending from the symphysis pubis to the top of the fundus in the midline. C Striae gravidarum or stretch marks appear in 50% to 90% of pregnant women during the second half of pregnancy. They most often occur on the breasts and abdomen. This integumentary alteration is the result of separation within the underlying connective (collagen) tissue. D Angiomas and other changes also may appear.
A woman in her first trimester of pregnancy can expect to visit her physician every 4 weeks so that a. She develops trust in the health care team. b. Her questions about labor can be answered. c. The condition of the expectant mother and fetus can be monitored. d. Problems can be eliminated.
ANS: C Feedback A Developing a trusting relationship should be established during these visits, but that is not the primary reason. B Most women do not have questions concerning labor until the last trimester of the pregnancy. C This routine allows monitoring of maternal health and fetal growth and ensures that problems will be identified early. D All problems cannot be eliminated because of prenatal visits, but they can be identified.
One of the most effective methods for preventing venous stasis is to a. Wear elastic stockings in the afternoons. b. Sleep with the foot of the bed elevated. c. Rest often with the feet elevated. d. Sit with the legs crossed.
ANS: C Feedback A Elastic stockings should be applied before lowering the legs in the morning. B Elevating the legs at night may cause pressure on the diaphragm and increase breathing problems. C Elevating the feet and legs improves venous return and prevents venous stasis. D Sitting with the legs crossed will decrease circulation in the legs and increase venous stasis.
Centering pregnancy is an example of an alternative model of prenatal care. Which statement accurately applies to the centering model of care? a. Group sessions begin with the first prenatal visit. b. At each visit blood pressure, weight, and urine dipsticks are obtained by the nurse. c. Eight to 12 women are placed in gestational-age cohort groups. d. Outcomes are similar to traditional prenatal care.
ANS: C Feedback A Group sessions begin at 12 to 16 weeks of gestation and end with an early postpartum visit. Prior to group sessions, the patient has an individual assessment, physical examination, and history. B At the beginning of each group meeting, patients measure their own BP, weight, and urine dips and enter these in their record. Fetal heart rate assessment and fundal height are obtained by the nurse. C Gestational age cohorts comprise the groups, with approximately 8 to 12 women in each group. This group remains intact throughout the pregnancy. Individual follow-up visits are scheduled as needed. D Results evaluating this approach have been very promising. In a recent study of adolescent patients, there was a decrease in LBW infants and an increase in breastfeeding rates.
Which suggestion is appropriate for the pregnant woman who is experiencing nausea and vomiting? a. Eat only three meals a day so the stomach is empty between meals. b. Drink plenty of fluids with each meal. c. Eat dry crackers or toast before arising in the morning. d. Drink coffee or orange juice immediately on arising in the morning.
ANS: C Feedback A Instruct the woman to eat five to six small meals rather than three full meals per day. Nausea is more intense when the stomach is empty. B Fluids should be taken separately from meals. Fluids overstretch the stomach and may precipitate vomiting. C This will assist with the symptoms of morning sickness. It is also important for the woman to arise slowly. D Coffee and orange juice stimulate acid formation in the stomach. It is best to suggest eating dry carbohydrates when rising in the morning.
What comment by a new mother exhibits understanding of her toddler's response to a new sibling? a. "I can't believe he is sucking his thumb again." b. "He is being difficult, and I don't have time to deal with him." c. "My husband is going to stay with the baby so I can take our son to the park tomorrow." d. "When we brought the baby home, we made our son stop sleeping in the crib."
ANS: C Feedback A It is normal for a child to regress when a new sibling is introduced into the home. B The toddler may have feelings of jealousy and resentment toward the new baby taking the attention from him. Frequent reassurance of parental love and affection are important. C It is important for a mother to seek time alone with her toddler to reassure him that he is loved. D Changes in sleeping arrangements should be made several weeks before the birth so that the child does not feel displaced by the new baby.
To relieve a leg cramp, the patient should be instructed to a. Massage the affected muscle. b. Stretch and point the toe. c. Dorsiflex the foot. d. Apply a warm pack.
ANS: C Feedback A Since she is prone to blood clots in the legs, massaging the affected leg muscle is contraindicated. B Pointing the toes will contract the muscle and not relieve the pain. C Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle contraction. D Warm packs can be used to relax the muscle, but more immediate relief is necessary, such as dorsiflexion of the foot.
A patient who is 7 months pregnant states, "I'm worried that something will happen to my baby." The nurse's best response is a. "There is nothing to worry about." b. "The doctor is taking good care of you and your baby." c. "Tell me about your concerns." d. "Your baby is doing fine."
ANS: C Feedback A This statement is belittling the patient's concerns. B This statement is belittling the patient's concerns by telling her she should not worry. C Encouraging the client to discuss her feelings is the best approach. Women during their third trimester need reassurance that such fears are not unusual in pregnancy. D This statement disregards the patient's feelings and treats them as unimportant.
Which patient at term should go to the hospital or birth center the soonest after labor begins? a. Gravida 2 para 1 who lives 10 minutes away b. Gravida 1 para 0 who lives 40 minutes away c. Gravida 3 para 2 whose longest previous labor was 4 hours d. Gravida 2 para 1 whose first labor lasted 16 hours
ANS: C Feedback A A gravida 2 is expected to have a longer labor than the gravida 3. The fact that she lives close to the hospital allows her to stay home for a longer period of time. B A gravida 1 is expected to have the longest labor. C Multiparous women usually have shorter labors than do nulliparous women. The woman described in option c is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. D The gravida 2 is expected to have a longer labor than the gravida 3, especially since her first labor was 16 hours.
Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction? a. Amniotomy b. Intravenous Pitocin c. Transcervical catheter d. Vaginal insertion of prostaglandins
ANS: C Feedback A Amniotomy is a surgical method of augmentation and induction. B Intravenous Pitocin is a medical method of induction. C Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction. Other methods to expand and gradually dilate the cervix include Laminaria tents, Dilapan and Lamicel. D Insertion of prostaglandins is a medical method of induction.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.
ANS: C Feedback A Birth of the head occurs when the station is +4. A 0 station indicates engagement. B Bloody show occurs throughout the labor process and is not an indication of an imminent birth. C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. D Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.
Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Descent b. Engagement c. Flexion d. Station
ANS: C Feedback A Descent is the moving of the fetus through the birth canal. B Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic inlet. C Flexion of the fetal head allows the smallest head diameters pass through the pelvis. D The station is the relationship of the fetal presenting part to the level of the ischial spines.
When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother's right side close to midline. What is the likely position of the fetus? a. ROA b. LSP c. RSA d. LOA
ANS: C Feedback A Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother's right side denotes the location of the presenting part in the mother's pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. RO/A/ denotes a fetus that is positioned anteriorly in the right side of the maternal pelvis with the occiput as the presenting part. B Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother's right side denotes the location of the presenting part in the mother's pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. LSP describes a fetus that is positioned posteriorly in the left side of the pelvis with the sacrum as the presenting part. C Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother's right side denotes the location of the presenting part in the mother's pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RS/A/ is the correct three-letter abbreviation to indicate this fetal position. D Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother's right side denotes the location of the presenting part in the mother's pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. /A/ fetus that is LOA, would be positioned anteriorly in the left side of the pelvis with the occiput as the presenting part.
The nurse caring for a woman in labor understands that the primary risk associated with an amniotomy is a. Maternal infection b. Maternal hemorrhage c. Prolapse of the umbilical cord d. Separation of the placenta
ANS: C Feedback A Infection is a risk of amniotomy, but not the primary concern. B Maternal hemorrhage is not associated with amniotomy. C When the membranes are ruptured, the umbilical cord may come downward with the flow of amniotic fluid and become trapped in front of the presenting part. D This may occur if the uterus is overdistended before the amniotomy, but it is not the major concern.
What results from the adaptation of the fetus to the size and shape of the pelvis? a. Lightening b. Lie c. Molding d. Presentation
ANS: C Feedback A Lightening is the descent of the fetus toward the pelvic inlet before labor. B Lie is the relationship of the long axis of the fetus to the long axis of the mother. C The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. D Presentation is the fetal part that first enters the pelvic inlet.
To monitor for potential hemorrhage in the woman who has just had a cesarean birth, the recovery room nurse should a. Maintain an intravenous infusion at 100 mL/hr. b. Assess the abdominal dressings for drainage. c. Assess the uterus for firmness every 15 minutes. d. Monitor her urinary output.
ANS: C Feedback A Maintaining proper fluid balance will not control hemorrhage. B This is an important assessment, but hemorrhage will first be noted vaginally. C Maintaining contraction of the uterus is important in controlling bleeding from the placental site. D This is an important assessment to prevent future hemorrhaging from occurring, but it is not the first priority assessment in the recovery room.
The priority nursing care associated with an oxytocin (Pitocin) infusion is a. Measuring urinary output b. Increasing infusion rate every 30 minutes c. Monitoring uterine response d. Evaluating cervical dilation
ANS: C Feedback A Monitoring urinary output is important with Pitocin, but not the top priority. B The infusion rate may be increased, but only after proper assessment that it is appropriate. C Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse's priority intervention is monitoring uterine response. D Monitoring labor progression is important, but not the top priority.
During labor, a vaginal examination should be performed only when necessary because of the risk of a. Fetal injury b. Discomfort c. Infection d. Perineal trauma
ANS: C Feedback A Properly performed vaginal examinations should not cause fetal injury. B Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. C Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. D A properly performed vaginal examination should not cause perineal trauma.
The nurse thoroughly dries the infant immediately after birth primarily to a. Stimulate crying and lung expansion. b. Remove maternal blood from the skin surface. c. Reduce heat loss from evaporation. d. Increase blood supply to the hands and feet.
ANS: C Feedback A Rubbing the infant does stimulate crying, but it is not the main reason for drying the infant. B Drying the infant after birth does not remove all of the maternal blood. C Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. D The main purpose of drying the infant is to prevent heat loss.
31. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. What is the Apgar score for this infant? a. 7 b. 8 c. 9 d. 10
ANS: C Feedback A The baby received 2 points for each of the categories except color. Since the infant's hands and feet were blue this category is given a grade of 1. B The baby received 2 points for each of the categories except color. Since the infant's hands and feet were blue this category is given a grade of 1. C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. D The infant had 1 point deducted because of the blue color of the hands and feet.
To provide safe care for the woman, the nurse understands that which condition is a contraindication for an amniotomy? a. Dilation less than 3 cm b. Cephalic presentation c. -2 station d. Right occiput posterior position
ANS: C Feedback A The dilation must be enough to determine labor. B The presenting part should be cephalic. Amniotomy is deferred if the presenting part is higher in the pelvis. C A prolapsed cord can occur if the membranes artificially rupture when the presenting part is not engaged. D This indicates a cephalic presentation, which is appropriate for an amniotomy.
The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products a. Continues except when placental functions are reduced b. Increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Is not significantly affected
ANS: C Feedback A The maternal blood supply to the placenta gradually stops with contractions. B The exchange of oxygen and waste products decreases. C During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. D The exchange of oxygen and waste products is affected by contractions.
The greatest risk to the newborn after an elective cesarean birth is a. Trauma due to manipulation during delivery b. Tachypnea due to maternal anesthesia c. Prematurity due to miscalculation of gestation d. Tachycardia due to maternal narcotics
ANS: C Feedback A There is reduced trauma with a cesarean birth. B Maternal anesthesia may cause respiratory distress. C Regardless of the many criteria used to determine gestational age, inadvertent preterm birth still occurs. D Maternal narcotics may cause respiratory distress.
8. To initiate the milk ejection reflex, the mother should a. Wear a firm-fitting bra. b. Drink plenty of fluids. c. Place the infant to the breast d. Apply cool packs to her breast.
ANS: C Feedback A A firm bra is important to support the breast, but will not initiate the let-down reflex. B Drinking plenty of fluids is necessary for adequate milk production, but will not initiate the let-down reflex. C Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. D Cool packs to the breast will decrease the let-down reflex.
5. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous woman with ruptured membranes c. A multiparous woman at 39 weeks of gestation who is expecting twins d. A primigravida woman who has requested no analgesia during her labor
ANS: C Feedback A A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. B There is no indication that this woman's uterus is overdistended, which is the main cause of hypotonic dysfunction. C Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. D A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
14. When the nurse is in the process of health teaching it is very important that he or she consider the family's cultural beliefs regarding child care. One of these beliefs includes a. Arab women are anxious to breastfeed while still in the hospital. b. It is important to complement Asian parents about their new baby. c. Women from India tie a black thread around the infant's waist. d. In the Korean culture the patient's mother is the primary caregiver of the infant.
ANS: C Feedback A Arab women are hesitant to breastfeed in the birth facility and wish to wait until they are home and their milk comes in. B Asian parents may be uneasy when caregivers are too complementary about the baby or casually touch the infant's head. C Women from India may tie a black thread around the infant's wrist, ankle, or waist to ward off evil spirits. This thread should not be removed by the nurse. D In the Korean culture, the husband's mother is the primary caregiver for the infant and the mother during the early weeks.
9. What is the first step in assisting the breastfeeding mother? a. Provide instruction on the composition of breast milk. b. Discuss the hormonal changes that trigger the milk ejection reflex. c. Assess the woman's knowledge of breastfeeding. d. Help her obtain a comfortable position and place the infant to the breast.
ANS: C Feedback A Assessment should occur before instruction. B This may be part of the instructional plan, but assessment should occur first to determine what instruction is needed. C The nurse should first assess the woman's knowledge and skill in breastfeeding to determine her teaching needs. D This may be part of the instructional plan, but assessment should occur first to determine what instruction is needed.
21. A woman who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." b. "Acetaminophen is acceptable during pregnancy; however, you should not take aspirin." c. "You should come into the office and let the doctor check you." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."
ANS: C Feedback A Back pain can also be a symptom of preterm labor and needs to be assessed. B The woman needs to be assessed for preterm labor before providing pain relief. C A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. D The woman needs to be assessed for preterm labor before providing pain relief.
18. What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at station -3 d. Meconium-stained amniotic fluid
ANS: C Feedback A Hydramnios puts the woman at high risk for a prolapsed umbilical cord. B A very small fetus, normally preterm, puts the woman at risk for a prolapsed umbilical cord. C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. D Meconium-stained amniotic fluid shows that the fetus already has been compromised, but it does not increase the chance of a prolapsed cord.
7. A woman is having her first child. She has been in labor for 15 hours. Two hours ago, her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago, her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Secondary arrest d. Protracted descent
ANS: C Feedback A In the nulliparous woman, a prolonged latent phase typically lasts more than 20 hours. B A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). C With a secondary arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, indicating an arrest of labor. D With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.
12. In planning for home care of a woman with preterm labor, the nurse needs to address which concern? a. Nursing assessments will be different from those done in the hospital setting. b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers will be necessary.
ANS: C Feedback A Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. B Restricted activity and medication may prevent preterm labor; however, not in all women. Additionally, the plan of care is individualized to meet the needs of each patient. C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. D Many women will receive home health nurse visits, but care is individualized for each woman.
9. As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is a. To protect the baby from infection b. It is part of the Apgar protocol c. To protect the nurse from contamination by the newborn d. Because the nurse has primary responsibility for the baby during the first 2 hours
ANS: C Feedback A Proper hand hygiene is all that is necessary to protect the infant from infection. B Wearing gloves is not necessary in order to complete the Apgar score assessment. C With the possibility of transmission of viruses such as HBV and HIV through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. D The nurse assigned to the mother-baby couplet has primary responsibility regardless of whether or not she wears gloves.
25. A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she a. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition b. Warms the bottles using a microwave oven c. Burps her infant during and after the feeding as needed d. Refrigerates any leftover formula for the next feeding
ANS: C Feedback A Solid food should not be introduced to the infant for at least 4 to 6 months after birth. B A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. C Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding and after the feeding. D Any formula left in the bottle after the feeding should be discarded, because the infant's saliva has mixed with it.
10. With regard to lab tests and diagnostic tests in the hospital after birth, nurses should be aware that a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.
ANS: C Feedback A States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. B Federal law mandates newborn genetic screening; however, parents can decline testing. A waiver should be signed and a notation made in the infant's medical record. C If testing is done prior to 24 hours of age, genetic screening should be repeated when the infant is 1 to 2 weeks old. D Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the U.S. the majority (95%) of infants are screened for hearing loss prior to discharge from the hospital.
9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. Give supplemental oxygen with a small facemask. b. Encourage the parents to hold the infant. c. Palpate the infant's clavicles. d. Perform a complete newborn assessment.
ANS: C Feedback A The Apgar indicates that no respiratory interventions are needed. B The infant needs to be assessed for clavicle fractures before excessive movement. C Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. D A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant.
16. As the nurse assists a new mother with breastfeeding, she asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains a. More calories b. Essential amino acids c. Important immunoglobulins d. More calcium
ANS: C Feedback A The calorie count of formula and breast milk is about the same. B All of the essential amino acids are in both formula and breast milk. The concentrations may differ. C Breast milk contains immunoglobulins that protect the newborn against infection. D Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly.
1. A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital, 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base her reply? a. After circumcision, the diaper should be changed frequently and fastened snugly. b. This yellow crust is an early sign of infection. c. The yellow crust should not be removed. d. Discontinue the use of petroleum jelly to the tip of the penis.
ANS: C Feedback A The diaper should be fastened loosely to prevent rubbing or pressure on the incision site. B The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. C Crust is a normal part of healing. D The only contraindication for petroleum jelly is the use of a PlastiBell.
14. How many ounces will a formula fed infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? a. 0.5 to 1 b. 1 to 2 c. 2 to 3 d. 4
ANS: C Feedback A The infant takes 0.5 to 1 ounce per feeding during the first day of life. B This is too small an amount to meet calorie needs. C The newborn requires approximately 2 to 3 ounces per feeding within one week after birth. D Four ounces with every feeding would be overfeeding the infant.
3. The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can easily be cleared with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.
ANS: C Feedback A The nasal passages should be suctioned one nostril at a time. The mouth should always be suctioned first. B After compression of the bulb it should be inserted into one side of the mouth. If it is inserted into the center of the mouth, the gag reflex is likely to be initiated. C The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. D When the infant's cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed again.
8. The nurse administers vitamin K to the newborn for what reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.
ANS: C Feedback A Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. B Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. C This is an accurate statement. D Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.
6. A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor? a. She is exhibiting hypotonic uterine dysfunction. b. She is experiencing a normal latent stage. c. She is exhibiting hypertonic uterine dysfunction. d. She is experiencing pelvic dystocia.
ANS: C Feedback A With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor and then the contractions become weak and inefficient or stop altogether. B The contraction pattern seen in this woman signifies hypertonic uterine activity. C Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. D Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.
38. A nurse receives handoff report. Which newborn should the nurse assess first? a. Temperature 97.7° F (36.5° C) b. Pulse 144 beats/minute c. Respiratory rate 78 breaths/minute d. Glucose reading 58 mg/dL
ANS: C A newborn's respiratory rate should be 30 to 60 breaths/minute, so the nurse needs to assess the infant with the high respiratory rate first. The other values are within normal limits. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing REF: p. 435 OBJ: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment
5. The nurse understands that respirations are initiated at birth as a result of a. an increase in the PO2 and a decrease in PCO2. b. the continued functioning of the foramen ovale. c. chemical, thermal, sensory, and mechanical factors. d. drying off the infant.
ANS: C A variety of these factors are responsible for initiation of respirations. The PO2 decreases at birth and the PCO2 increases. The foramen ovale closes at birth. Tactile stimuli aid in initiating respirations but are not the main cause. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 425 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. To increase the absorption of iron in a pregnant woman, the nurse teaches her that iron preparations should be given with a. milk. b. tea. c. orange juice. d. coffee.
ANS: C A vitamin C source may increase the absorption of iron. The calcium and phosphorus in milk decrease iron absorption. Tannin in the tea reduces the absorption of iron. Coffee reduces iron absorption. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Patient-Centered Teaching Box| p. 262 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9. The nurse-midwife is concerned that a woman's uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. On the basis of this information, the nurse should obtain a(n) a. tocotransducer. b. scalp electrode. c. intrauterine pressure catheter. d. Doppler transducer.
ANS: C An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this not be accurate with obesity. A scalp electrode measures the fetal heart rate (FHR). A Doppler auscultates the FHR. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 339 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
19. To prevent heat loss from convection in a newborn, which action by the nurse is best? a. Place the baby in a warmer. b. Dry the baby after a bath. c. Move infant away from blowing fan. d. Wrap the baby in warmed blankets.
ANS: C Convection occurs when infants are exposed to cold air currents. Moving the baby out of the fan's air currents will reduce this loss. The warmer prevents heat loss from radiant heat loss. Drying the baby prevents evaporative heat loss. Warm blankets prevent conductive heat loss. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 427 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
3. The nursing student is planning to assess a fetal heart rate. The registered nurse reminds the student to get gel. Which method of assessing the fetal heart rate is the student planning on conducting? a. Fetoscope b. Tocodynamometer c. Doppler d. Scalp electrode
ANS: C Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires use of a gel. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 338 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
11. A laboring woman has been given an injection of epidural anesthesia. Which assessment by the nurse takes priority? a. Urinary output b. Contraction pattern c. Maternal blood pressure d. Intravenous infusion rate
ANS: C Epidural anesthesia may produce maternal hypotension due to vasodilation so the priority assessment by the nurse is maternal blood pressure. The other assessments are important for this woman but are not directly related to the anesthetic injection. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 372 | Table 18.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
13. Which woman will most likely have increased anxiety and tension during her labor? a. Gravida 1 who did not attend prepared childbirth classes b. Gravida 2 who refused any medication c. Gravida 2 who delivered a stillborn baby last year d. Gravida 3 who has two children younger than 3 years
ANS: C If a previous pregnancy had a poor outcome, the woman will probably be more anxious during labor and delivery. The woman is not prepared for labor and will have increased anxiety during labor. However, the woman with a poor previous outcome is more likely to experience more anxiety, and good teaching by the nurse will diminish some of the anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 356 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
15. The laboring woman who imagines her body opening to let the baby out is using a mental technique called a. dissociation. b. effleurage. c. imagery. d. distraction.
ANS: C Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 359 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
10. What is a result of hypothermia in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate
ANS: C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 427 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
18. In which infant behavioral state is bonding most likely to occur? a. Drowsy b. Active alert c. Quiet alert d. Crying
ANS: C In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the mother or father or both. In the drowsy state the eyes may remain closed. If open they are unfocused. The infant is not interested in the environment at this time. In the active alert state infants are often fussy, restless, and not focused. During the crying state the infant does not respond to stimulation and cannot focus on parents. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 435 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
16. Which statement is correct regarding the fluid balance in a newborn versus that in an adult? a. The infant has a smaller percentage of surface area to body mass. b. The infant has a smaller percentage of water to body mass. c. The infant has a greater percentage of insensible water loss. d. The infant has a 50% more effective glomerular filtration rate.
ANS: C Insensible water loss is greater in the infant due to the newborn's large body surface area and rapid respiratory rate. The infant's surface area is large compared to an adult's. Infants have a larger percentage of water to body mass. The filtration rate is less than in adults because the kidneys are immature in a newborn. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 434 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
15. The nurse notes a pattern of late decelerations on the fetal monitor. The most appropriate action is to a. continue observation of this reassuring pattern. b. notify the physician or nurse-midwife. c. give the woman oxygen by face mask. d. place the woman in a Trendelenburg position.
ANS: C Late decelerations are associated with reduced placental perfusion. Giving the laboring woman oxygen increases the oxygen saturation in her blood, making more oxygen available to the fetus. This is not a reassuring pattern; interventions are needed. Nursing interventions should be initiated before notifying the health care provider. The Trendelenburg position will not increase the placental perfusion. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 342 | p. 344 | Safety Alert Box OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
13. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. seen at age 3 days. b. the residue of a milk curd. c. passed in the first 12 hours of life. d. lighter in color and looser in consistency.
ANS: C Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected. It is dark in color and sticky and develops from matter in the intestines during intrauterine life. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 431 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
28. What characteristic shows the greatest gestational maturity? a. Few rugae on the scrotum and testes high in the scrotum b. Infant's arms and legs extended c. Some peeling and cracking of the skin d. The arm can be positioned with the elbow beyond the midline of the chest
ANS: C Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. The other signs are indicative of a younger gestational age. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 437 | Table 21.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."
ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 433 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
Childbirth preparation can be considered successful if the outcome is described as follows: a. Labor and delivery were pain-free. b. The woman's partner participated eagerly. c. The woman rehearsed labor and practiced skills to master pain. d. Only nonpharmacologic methods for pain control were used.
ANS: C Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia/analgesia realistically. The partner's role and participation level should be established by the couple. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone. PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating REF: p. 356 OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity
32. A woman had an epidural place an hour ago and is now complaining of severe itching. What action by the nurse is most appropriate? a. Discontinue the epidural infusion at once. b. Notify the anesthesia provider. c. Prepare to administer diphenhydramine (Benedryl). d. Prepare to administer promethazine (Phenergan).
ANS: C Pruritis (itching) is a common side effect of epidural medications. The nurse should be prepared to administer diphenhydramine. There is no need to discontinue the epidural infusion or notify the anesthesia provider. Promethazine is used for nausea. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 18.1 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
14. The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated? a. Lower the head of the bed. b. Place the mother in a Trendelenburg position. c. Change her position to the right side. d. Place a wedge under the left hip.
ANS: C Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. The other actions are not warranted. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 347 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
25. A newborn who is large for gestational age (LGA) is _________ percentile for weight. a. below the 90th b. less than the 10th c. greater than the 90th d. between the 10th and 90th
ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 458 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
12. A nurse is administering vitamin K to an infant shortly after birth. The parents ask why their baby needs a shot. The nurse explains that vitamin K is a. important in the production of red blood cells. b. necessary in the production of platelets. c. not initially synthesized because of a sterile bowel at birth. d. responsible for the breakdown of bilirubin and prevention of jaundice.
ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is vital for clotting, so without it the infant is at increased risk of bleeding problems. It is not needed to produce red blood cells, platelets, or break down bilirubin. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 430 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
10. The nurse is counseling a woman in her third trimester about eating enough protein. If the woman already gets her non-pregnant RDA of protein, how much more does she need in her diet? a. 5 grams/day b. 10 grams/day c. 25 grams/day d. 30 grams/day
ANS: C The current RDA for protein in the non-pregnant woman is 46 grams. To reach the recommendation for protein in the second half of pregnancy (71 grams), the patient needs to add 25 more grams of protein to her diet daily. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 14.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. A student nurse in the perinatal clinic sees the term "pica" on a woman's chart and asks the registered nurse what this means. What definition is most accurate? a. Intolerance of milk products b. Iron deficiency anemia c. Ingestion of nonfood substances d. Episodes of anorexia and vomiting
ANS: C The practice of eating substances not normally thought of as food is called pica. Clay or dirt and solid laundry starch are the substances most commonly ingested. It is not intolerance of milk products, iron deficiency anemia, or episodes of anorexia and vomiting. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 267 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
17. Which nursing action is correct when initiating electronic fetal monitoring? a. Lubricate the tocotransducer with an ultrasound gel. b. Inform the patient that she should remain in the semi-Fowler's position. c. Securely apply the tocotransducer with a strap or belt. d. Determine the position of the fetus before attaching the electrode.
ANS: C The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately. The tocotransducer does not need gel to operate appropriately. The patient should be encouraged to move around during labor. The tocotransducer should be placed at the fundal area of the uterus. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 338 | Procedure Box OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
17. A pregnant woman's diet consists almost entirely of whole grain breads and cereals, fruits, and vegetables. The nurse should be most concerned about this woman's intake of which nutrient? a. Calcium b. Protein c. Vitamin B12 d. Folic acid
ANS: C This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because vitamin B12 is found in foods of animal origin, this diet is deficient in vitamin B12. Depending upon the woman's food choices this diet may be adequate in calcium, protein, and folic acid. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 266 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
23. A maculopapular rash with a red base and a small white papule in the center is a. milia. b. mongolian spots. c. erythema toxicum. d. café au lait spots.
ANS: C This is a description of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Café au lait spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns, but they can indicate a genetic disorder. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 435 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
12. Which statement is true about the physiologic effects of pain in labor? a. It usually results in a more rapid labor. b. It is considered to be a normal occurrence. c. It may result in decreased placental perfusion. d. It has no effect on the outcome of labor.
ANS: C When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor due to increased anxiety in the woman. Pain is considered normal for labor, however; this statement does not explain the physiologic effects. Pain may affect the outcome of the labor depending on the cause and the effect on the woman. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 354 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. The nurse is caring for a laboring patient who develops a fever after she has had her epidural initiated. What actions by the nurse are appropriate? (Select all that apply.) a. Palpate the woman's bladder distention. b. Assess the woman's blood pressure. c. Observe the woman for shivering. d. Check the skin for color and warmth. e. Prepare to assist with a blood patch.
ANS: C, D Heat dissipation is reduced as a result of decreased hyperventilation, sweating, and activity after the onset of pain relief. Vasodilation redistributes heat from the core to the periphery of the body, where it is lost to the environment. Assessing the skin will demonstrate findings consistent with vasodilation. Shivering often occurs with sympathetic blockade accompanied by a dissociation between warm and cold sensations. In essence, the body believes that the temperature is lower than it actually is and turns up the "thermostat." Bladder distention is an anticipated effect of having an epidural. A woman's bladder fills quickly because of the large quantity of IV solution, yet her sensation to void is reduced. Maternal hypotension is an expected side effect of epidural initiation. The nurse should assess the bladder and blood pressure, but these actions are not related to the fever. A blood patch procedure is not warranted for this patient. PTS: 1 DIF: Cognitive Level: Application REF: p. 364 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alterations? (Select all that apply.) a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension
ANS: C, E Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure, and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the cord is around the baby's neck, arm, leg or other body part, a short cord, a knot in the cord, or a prolapsed cord. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Table 17.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
While assessing her patient, what does the nurse interpret as a positive sign of pregnancy? a. Fetal movement felt by the woman b. Amenorrhea c. Breast changes d. Visualization of fetus by ultrasound
ANS: D Feedback A Fetal movement is a presumptive sign of pregnancy. B Amenorrhea is a presumptive sign of pregnancy. C Breast changes are a presumptive sign of pregnancy. D The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner.
While you are assessing the vital signs of a pregnant woman in her third trimester, the patient complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? a. Have the patient stand up and retake her blood pressure. b. Have the patient sit down and hold her arm in a dependent position. c. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms. d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
ANS: D Feedback A Pressures are significantly higher when the patient is standing. This option causes an increase in systolic and diastolic pressures. B The arm should be supported at the same level of the heart. C The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension. D Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension.
A pregnant woman has come to the emergency department with complaints of nasal congestion and epistaxis. What is the correct interpretation of these symptoms by the practitioner? a. These conditions are abnormal. Refer the patient to an ear, nose, and throat specialist. b. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.
ANS: D Feedback A The patient should be reassured that these symptoms are within normal limits. No referral is needed at this time. B Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone levels increase during pregnancy. C Progesterone affects relaxation of the smooth muscles in the respiratory tract. D As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy.
The maternal task that begins in the first trimester and continues throughout the neonatal period is called a. Seeking safe passage for herself and her baby b. Securing acceptance of the baby by others c. Learning to give of herself d. Developing attachment with the baby
ANS: D Feedback A This is a task that ends with delivery. During this task the woman seeks health care and cultural practices. B This process continues throughout pregnancy as the woman reworks relationships. C This task occurs during pregnancy as the woman allows her body to give space to the fetus. She continues with giving to others in the form of food or presents. D Developing attachment (strong ties of affection) to the unborn baby begins in early pregnancy when the woman accepts that she is pregnant. By the second trimester, the baby becomes real and feelings of love and attachment surge.
A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? a. "My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." b. "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." c. "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." d. "We do not want the fetal monitor used during labor, since it will interfere with movement and doing effleurage."
ANS: D Feedback A This is an acceptable request for a laboring woman. B Using breathing techniques to alleviate pain is a realistic part of a birth plan. C Not all fathers are able to be present during the birth; however, this couple has made a realistic plan that works for their specific situation. D Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and as long as labor is progressing normally. The birth plan is a tool with which parents can explore their childbirth options; however, the plan must be viewed as tentative.
A step in maternal role attainment that relates to the woman giving up certain aspects of her previous life is termed a. Looking for a fit b. Roleplaying c. Fantasy d. Grief work
ANS: D Feedback A This is when the woman observes the behaviors of mothers and compares them with her own expectations. B Roleplaying involves searching for opportunities to provide care for infants in the presence of another person. C Fantasies allow the woman to try on a variety of behaviors. This usually deals with how the child will look and the characteristics of the child. D The woman experiences sadness as she realizes that she must give up certain aspects of her previous self and that she can never go back.
Which assessment finding could indicate hemorrhage in the postpartum patient? a. Firm fundus at the midline b. Saturation of two perineal pads in 4 hours c. Elevated blood pressure d. Elevated pulse rate
ANS: D Feedback A A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. B Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits. C If the blood volume were diminishing, the blood pressure would decrease. D An increasing pulse rate is an early sign of excessive blood loss.
When preparing a woman for a cesarean birth, the nurse's care should include a. Injection of narcotic preoperative medications b. Full perineal shave preparation c. Straight catheterization to empty the bladder d. Administration of an oral antacid
ANS: D Feedback A A narcotic at this point would put the fetus at high risk for respiratory distress. B Perineal preparation is not necessary for a cesarean section. Some agencies will do an abdominal prep just before the surgery. C The catheterization should be indwelling in order to keep the bladder small during the surgery. D General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes gastric acid and reduces potential lung injury if the woman vomits and aspirates gastric contents during anesthesia.
What finding should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Contractions lasting 90 seconds c. FHR in the 140s d. Meconium-stained amniotic fluid
ANS: D Feedback A Active fetal movement is an expected occurrence. B The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. C Expected FHR range is from 120 to 160. D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid.
The standard of care for obstetrics dictates that an internal version might be used to manipulate the a. Fetus from a breech to a cephalic presentation before labor begins b. Fetus from a transverse lie to a longitudinal lie before cesarean birth c. Second twin from an oblique lie to a transverse lie before labor begins d. Second twin from a transverse lie to a breech presentation during vaginal birth
ANS: D Feedback A For internal version to occur, the cervix needs to be completely dilated. B For internal version to occur, the cervix needs to be dilated. C Internal version is done to turn the second twin after the first twin is born. D Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally.
The nurse practicing in a labor setting knows that the woman most at risk for a uterine rupture is a gravida a. 3 who has had two low-segment transverse cesarean births b. 2 who had a low-segment vertical incision for delivery of a 10-pound infant c. 5 who had two vaginal births and two cesarean births d. 4 who has had all cesarean births
ANS: D Feedback A Low-segment transverse cesarean scars do not predispose her to uterine rupture. B Low-segment incisions do not raise the risk of uterine ruptures. C This woman is not a high-risk candidate. D The risk of uterine rupture increases as the number of prior uterine incisions increases. More than 2 previous cesarean births places the woman at increased risk for uterine rupture.
Which comfort measure should the nurse use to assist the laboring woman to relax? a. Keep the room lights lit so that the patient and her coach can see everything. b. Offer warm, wet cloths to use on the patient's face and neck. c. Palpate her filling bladder every 15 minutes. d. Recommend frequent position changes.
ANS: D Feedback A Soft, indirect lighting is more soothing than irritating bright lights. B Women in labor become hot and perspire. Cool cloths are much better C A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. D Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent.
To adequately care for patients, the nurse understands that labor contractions facilitate cervical dilation by a. Contracting the lower uterine segment b. Enlarging the internal size of the uterus c. Promoting blood flow to the cervix d. Pulling the cervix over the fetus and amniotic sac
ANS: D Feedback A The contractions are stronger at the fundus. B The internal size becomes smaller with the contractions; this helps to push the fetus down. C Blood flow decreases to the uterus during a contraction. D Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward.
A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate "labor is getting closer to starting." The nurse informs the woman that which of the following is a sign that labor may begin soon? a. Weight gain of 1.5 to 2 kg (3 to 4 lb) b. Increase in fundal height c. Urinary retention d. Surge of energy
ANS: D Feedback A The woman may lose 0.5 to 1.5 kg, the result of water loss caused by electrolyte shifts, which in turn are caused by changes in the estrogen and progesterone levels. B When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. C Urinary frequency may return before labor. D Women speak of having a burst of energy before labor.
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be a. Admitted and prepared for a cesarean birth b. Admitted for extended observation c. Discharged home with a sedative d. Discharged home to await the onset of true labor
ANS: D Feedback A These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated. B These are all indications of false labor; there is no indication that further assessment or observations are indicated. C The patient will probably be discharged, but there is no indication that a sedative is needed. D The situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins.
The priority nursing intervention after an amniotomy is to a. Assess the color of the amniotic fluid. b. Change the patient's gown. c. Estimate the amount of amniotic fluid. d. Assess the fetal heart rate.
ANS: D Feedback A This is important, but not the top priority. B This is important for patient comfort, but it is not the top priority. C This is not a top priority for this patient. D The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred.
17. Which action should be initiated to limit hypovolemic shock when uterine inversion occurs? a. Administer oxygen at 31 L/min by nasal cannula. b. Administer an oxytocic drug by intravenous push. c. Monitor fetal heart rate every 5 minutes. d. Restore circulating blood volume by increasing the intravenous infusion rate.
ANS: D Feedback A Administering oxygen will not prevent hypovolemic shock. B Oxytocin drugs should not be given until the uterus is repositioned. C A uterine inversion occurs during the third stage of labor. D Intravenous fluids are necessary to replace the lost blood volume that occurs in uterine inversion.
4. In providing and teaching cord care, what is an important principle? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. The process of keeping the cord dry will decrease bacterial growth.
ANS: D Feedback A Cord care is to prevent infection and add in the drying of the cord. B No agents are necessary to facilitate drying of the cord. C The cord will fall off within 10 to 14 days. D Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth.
3. How can the nurse help the mother who is breastfeeding and has engorged breasts? a. Suggest that she switch to bottled formula just for today. b. Assist her into removing her bra, making her more comfortable. c. Apply heat to her breasts between feeding and cold to the breasts just before feedings. d. Instruct and assist the mother to massage her breasts.
ANS: D Feedback A Engorgement is more likely to increase if breastfeeding is delayed or infrequent. B A well-fitting bra should be worn both day and night to support the breasts. C Cold applications are used between feedings to reduce edema and pain. Heat is applied just before feedings to increase vasodilation. D Massage of the breasts causes release of oxytocin and increases the speed of milk release.
14. With regard to the care management of preterm labor, nurses should be aware that a. Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms. b. Braxton Hicks contractions often signal the onset of preterm labor. c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.
ANS: D Feedback A It is essential that nurses teach women how to detect the early symptoms of preterm labor. B Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. C Waiting too long to see a health care provider could result in essential medications' failing to be administered. Preterm labor is not necessarily long-term labor. D Gestational age of 20 to 37 weeks, uterine contractions, and a thinning cervix are all indications of preterm labor.
17. When responding to the question "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" the nurse should explain that a. The breast milk will gradually become richer to supply additional calories. b. As the infant requires more milk, feedings can be supplemented with cow's milk. c. Early addition of baby food will meet the infant's needs. d. The mother's milk supply will increase as the infant demands more at each feeding.
ANS: D Feedback A Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. B Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. C Solids should not be added until about 4 to 6 months, when the infant's immune system is more mature. This will decrease the chance of allergy formations. D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant.
27. All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby Friendly Hospital Initiative endorsed by WHO and Unicef was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which is not one of the "Ten Steps to Successful Breastfeeding for Hospitals"? a. Give newborns no food or drink other than breast milk. b. Have a written breastfeeding policy that is communicated to all staff. c. Help mothers initiate breastfeeding within one half hour of birth. d. Give artificial teats or pacifiers as necessary.
ANS: D Feedback A No other food or drink should be given to the newborn unless medically indicated. B The breastfeeding policy should be routinely communicated to all health care staff. All staff should be trained in the skills necessary to maintain this policy. C Breastfeeding should be initiated within one half hour of birth and all mothers need to be shown how to maintain lactation even if separated from their babies. D No artificial teats or pacifiers (also called dummies or soothers) should be given to breastfeeding infants.
16. A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action is to a. Reposition the woman with her hips slightly elevated. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Notify the physician promptly and prepare the woman for surgery.
ANS: D Feedback A Repositioning the woman with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties. B Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the woman at high risk for uterine rupture. C The woman is now at high risk for shock. Nonadditive intravenous fluids should be increased. D Pain between the scapulae may occur when the uterus ruptures, because blood accumulates under the diaphragm. This is an emergency that requires medical intervention.
19. The fetus in a breech presentation is often born by cesarean delivery because a. The buttocks are much larger than the head. b. Postpartum hemorrhage is more likely if the woman delivers vaginally. c. Internal rotation cannot occur if the fetus is breech. d. Compression of the umbilical cord is more likely.
ANS: D Feedback A The head is the largest part of a fetus. B There is no relationship between breech presentation and postpartum hemorrhage. C Internal rotation can occur with a breech. D After the fetal legs and trunk emerge from the woman's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head.
10. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant a. With his arms folded together over his chest b. Curled up in a fetal position c. With his head cupped in her hand d. With his head and body in alignment
ANS: D Feedback A The infant should be facing the mother with his arms hugging the breast. B The baby's body should be held in correct alignment (ears, shoulder, hips in a straight line) during feedings. C The mother should support the baby's neck and shoulders with her hand and not push on the occiput. D The infant's head and body should be in correct alignment with the mother and the breast during latch-on and feeding.
11. A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who a. Sleeps for 6 hours at a time between feedings b. Has at least one breast milk stool every 24 hours c. Gains 1 to 2 ounces per week d. Has at least six to eight wet diapers per day
ANS: D Feedback A This is not an indication of whether the infant is breastfeeding well. Typically infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster-fed. B The infant should have a minimum of three bowel movements in a 24-hour period. C Breastfed infants typically gain 15 to 30 g/day. D After day 4, when the mother's milk comes in, the infant should have six to eight wet diapers every 24 hours.
6. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to a. Keep the state records updated. b. Allow accurate statistical information. c. Document the number of births. d. Recognize and treat newborn disorders early.
ANS: D Feedback A This is not the main reason for the screening test. B This is not the main reason for the screening test. C The number of births does not come from the newborn screening test. D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions.
10. A laboring patient in the latent phase is experiencing uncoordinated, irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." c. "Let me take off the monitor belts and help you get into a more comfortable position." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."
ANS: D Feedback A This statement is belittling the patient's complaints. Support and comfort are necessary. B Breathing will not decrease the pain. C It is important to get her into a more comfortable position, but fetal monitoring should continue. D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation.
12. A nurse is responsible for teaching new parents about the hygienic care of their newborn. The nurse should tell the parents to a. Avoid washing the head for at least 1 week to prevent heat loss. b. Sponge bathe only until the cord has fallen off. c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d. Water temperature should be at least 38° C.
ANS: D Feedback A To prevent heat loss, the infant's head should be bathed before unwrapping and undressing. B Tub baths may be initiated from birth. Ensure that the infant is fully immersed. C Q-tips should not be used, because they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose. D The ideal temperature of the bath water should be at least 38° C or 100.4° F.
15. Which nursing action must be initiated first when evidence of prolapsed cord is found? a. Notify the physician. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean delivery. d. Reposition the mother with her hips higher than her head.
ANS: D Feedback A Trying to relieve pressure on the cord should be the first priority. B Trying to relieve pressure on the cord should take priority over increasing fetal monitoring techniques. C Emergency cesarean delivery may be necessary if relief of the cord is not accomplished. D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed.
1. Which actions by the nurse may prevent infections in the labor and delivery area? a. Vaginal examinations every hour while the woman is in active labor b. Use of clean techniques for all procedures c. Cleaning secretions from the vaginal area by using back-to-front motion d. Keeping underpads and linens as dry as possible
ANS: D Feedback A Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. B Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. C Vaginal drainage should be removed with a front-to-back motion to decrease fecal contamination. D Bacterial growth prefers a moist, warm environment.
13. The difference between the aseptic and terminal methods of sterilization is that the a. Aseptic method does not require boiling of the bottles. b. Terminal method requires boiling water to be added to the formula. c. Aseptic method requires a longer preparation time. d. Terminal method sterilizes the prepared formula at the same time it sterilizes the equipment.
ANS: D Feedback A With the aseptic method, the bottles are boiled separate from the formula. B With the terminal method, the formula is prepared, placed in bottles, and everything is boiled at one time. C The terminal method takes 25 minutes to boil; the aseptic method takes 5 minutes to boil. D In the terminal sterilization method, the formula is prepared in the bottles, which are loosely capped, and then the bottles are placed in the sterilizer, where they are boiled for 25 minutes.
30. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called a. lanugo. b. vascular nevi. c. nevus flammeus. d. mongolian spots.
ANS: D A mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 435 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance
A woman had a chorionic villus sampling procedure. Prior to discharge the nurse should teach her to report what symptom that may be an indication of a complication? A. Lack of fetal movement B. Frequent urination C. Nausea and vomiting D. Vaginal bleeding or passage of amniotic fluid
ANS: D A. Chorionic villus sampling is done between 10 and 12 weeks of gestation. Fetal movement is not felt until about 16 weeks. B. Frequent urination is a common symptom of pregnancy during the first trimester. It is not an indication of procedural complications. C. Nausea and vomiting are a common symptom of pregnancy during the first trimester and not an indication of procedural complications. D. Vaginal bleeding or passage of amniotic fluid suggests possible miscarriage and should be reported.
17. An infant has an elevated immunoglobulin M (IgM) level. What action by the nurse is most appropriate? a. Encourage the mother to breastfeed the baby. b. Document the findings in the infant's chart. c. Assess the infant for other signs of allergy. d. Take a set of vital signs on the infant, and then notify the provider.
ANS: D An elevated level of IgM is associated with exposure to infection in utero because IgM does not cross the placenta. The nurse should take a set of vital signs and notify the provider so further investigation can occur. It is not related to breastfeeding or allergies. The information should be documented, but this is not the most important action. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 434 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
20. One of the greatest risks to the mother during administration of general anesthesia is a. respiratory depression. b. uterine relaxation. c. inadequate muscle relaxation. d. aspiration of stomach contents.
ANS: D Aspiration of acidic gastric contents and possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia, but this can be monitored and prevented. Inadequate muscle relaxation can be altered. This is not the greatest risk for the mother. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 367 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. The major source of nutrients in the diet of a pregnant woman should be composed of a. simple sugars. b. fats. c. fiber. d. complex carbohydrates.
ANS: D Complex carbohydrates supply the pregnant woman with vitamins, minerals, and fiber. The most common simple carbohydrate is table sugar, which is a source of energy but does not provide any nutrients. Fats provide 9 kcal in each gram, in contrast to carbohydrates and proteins, which provide only 4 kcal in each gram. However, fat is not a good source of nutrients. Fiber is supplied mainly by the complex carbohydrates. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 257 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
29. The nurse is concerned about an infection in a newborn. What finding does the nurse assess for? a. More than two soft stools per day b. Leukocytosis with a left shift c. Poor feeding behaviors d. An axillary temperature greater than 37.5 C
ANS: D Due to their immature immune system, newborns often do not have fever and leukocytosis with infection. Signs of infection are subtler and include changes in activity, tone, feeding, and color. More than two stools is an expected finding. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 434 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
26. Which type of cutaneous stimulation involves massage of the abdomen? a. Thermal stimulation b. Imagery c. Mental stimulation d. Effleurage
ANS: D Effleurage is massage usually performed on the abdomen during contractions. Thermal stimulation is the use of warmth to provide comfort, such as showers and baths. Imagery involves the woman creating a relaxing mental scene and dissociating herself from the painful aspects of labor. Mental stimulation occupies the woman's mind and competes with pain stimuli. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 357 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
16. The nurse explains to the student that increasing the infusion rate of non-additive intravenous fluids can increase fetal oxygenation primarily by a. maintaining normal maternal temperature. b. preventing normal maternal hypoglycemia. c. increasing the oxygen-carrying capacity of the maternal blood. d. expanding maternal blood volume.
ANS: D Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most intravenous fluids for laboring women are isotonic and do not improve hypoglycemia. Oxygen-carrying capacity is increased by adding more red blood cells. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 344 | Safety Alert Box OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
24. A pregnant woman is at a picnic and asks a friend of hers, who is a nurse, what foods she can eat. What response by the nurse is best? a. Bologna sandwich b. Hot dog c. Smoked salmon spread d. Cheddar cheese and crackers
ANS: D Hard cheeses like cheddar are safe for the pregnant woman to eat. She should not eat lunch meat or hotdogs unless they are heated until steaming. She should also not eat refrigerated smoked seafood. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 263 | Safety Alert Box OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
5. When providing labor support, the nurse knows that which fetal position might cause the laboring woman more back discomfort? a. Right occiput anterior b. Left occiput anterior c. Right occiput transverse d. Left occiput posterior
ANS: D In the left occiput posterior position, each contraction pushes the fetal head against the mother's sacrum, which results in intense back discomfort. The other fetal positions do not cause more back discomfort. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 358 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
17. The method of anesthesia in labor considered the safest for the fetus is the a. pudendal block. b. epidural block. c. spinal (subarachnoid) block. d. local infiltration.
ANS: D Local infiltration of the perineum rarely has any adverse effects on either the mother or the fetus. The fetus can be affected by maternal side effects of the other types of anesthesia. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 362 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
19. The precepting nurse explains to the newly hired nurse that when using IA for FHR which situation is unit protocol? a. The nurses can be expected to cover only two or three patients when IA is the primary method of fetal assessment. b. The best course is to use the descriptive terms associated with EFM when documenting results. c. If the heartbeat cannot be found immediately, a shift must be made to electronic monitoring. d. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.
ANS: D Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if that device is used to help locate the heartbeat. When used as the primary method of fetal assessment, auscultation requires a nurse-to-patient ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate. Electronic monitoring is not needed at this point. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 335 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
28. Which technique could the support person use when the laboring woman appears to be losing control? a. Have the nurse take over the role of support. b. Tell the woman that she is causing stress to her baby and herself. c. Wait for the contraction to end and discuss the problem with her. d. Make eye contact with the woman and breathe along with her.
ANS: D Making eye contact and breathing along with the laboring woman to help pace her breathing will assist her in remaining calm. The woman already has a trusting relationship with the support person so they should stay in that position if possible. Telling the woman she is stressing herself and the baby is very uncaring and will not be helpful. A woman who has lost control will not be able to engage in a productive discussion. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 371 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
9. A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available? a. Promethazine (Phenergan) b. Nalbuphine (Nubain) c. Butorphanol (Stadol) d. Naloxone (Narcan)
ANS: D Naloxone reverses narcotic-induced respiratory depression, which may occur with administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics that can be given to women in labor. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 372 | Table 18.2 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
14. Which method of pain management does the nurse plan for a gravida 3 para 2 admitted at 8-cm cervical dilation? a. Epidural anesthesia b. Narcotics c. Spinal block d. Breathing and relaxation techniques
ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. There is probably not enough remaining time to administer epidural anesthesia or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 357 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
ANS: D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. There is no need to notify the pediatrician. Surfactant is produced by the lungs, so aspiration is not a concern. Pneumothorax is also not a concern. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 425 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
11. The nurse needs to assess infants for the development of high levels of bilirubin. Which baby can the nurse check last? a. Was bruised during a difficult delivery b. Developed a cephalhematoma c. Was born prematurely d. Breastfeeds during the first hour of life
ANS: D The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation. Bruising, cephalhematomas, and prematurity increase the baby's risk of high bilirubin. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 432 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
Which pregnant woman should have the least weight gain during pregnancy? a. Woman pregnant with twins b. Woman in early adolescence c. Woman shorter than 62 inches or 157 cm d. Woman who was obese before pregnancy
ANS: D The recommended weight gain for overweight or obese women is 11 to 20 pounds. This will provide sufficient nutrients for the fetus. Overweight and obese women should be advised to lose weight prior to conception in order to achieve the best pregnancy outcomes. A higher weight gain in twin gestations may help prevent low birth weights. Adolescents need to gain weight toward the higher acceptable range, which will provide for their own growth as well as for fetal growth. In the past women of short stature were advised to restrict their weight gain; however, evidence to support these guidelines has not been found. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 255 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance;
21. A nurse might be called on to stimulate the fetal scalp a. as part of fetal scalp blood sampling. b. in response to tocolysis. c. in preparation for fetal oxygen saturation monitoring. d. to elicit an acceleration in the FHR.
ANS: D The scalp can be stimulated using digital pressure during a vaginal examination, which should cause an increase in FHR. Stimulating the fetal scalp is not part of blood sampling, assessing the response to tocolysis, or in preparation for oxygen saturation monitoring. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 345 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
6. The nurse teaches a pregnant woman that one danger in using nonfood supplementation of nutrients is a. increased absorption of all vitamins. b. development of pregnancy-induced hypertension (PIH). c. increased caloric intake. d. toxic effects on the fetus.
ANS: D The use of supplements in addition to food may increase the intake of some nutrients to doses much higher than the recommended amounts. Overdoses of some nutrients have been shown to cause fetal defects. Supplements do not have better absorption than natural vitamins and minerals. There is no relationship between supplements and PIH. Supplements do not contain significant calories. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 261 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
11. The nurse assesses the fetal monitor and sees the following strip. What action by the nurse is most appropriate? a. Administer oxygen by nasal cannula. b. Reposition the woman. c. Apply a fetal scalp electrode. d. Record this reassuring pattern.
ANS: D This is a reassuring pattern and no intervention is necessary beyond documentation. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing REF: Figure 17.6 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
41. A nurse is supervising a student nurse who is assessing an infant's rooting reflex. Which action by the student warrants further instruction by the nurse? a. Tells parents this reflex will disappear within 4 months b. Strokes face from side of mouth to cheek c. Notes normal findings when infant turns head toward touch d. Performs assessment on infant while sleeping
ANS: D This reflex is difficult to assess on an infant just after feeding or when asleep. The other actions by the student are correct. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 448 | Table 21.3 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
16. The traditional diet of Asian women includes little meat or dairy products and may be low in calcium and iron. The nurse can help the woman increase her intake of these foods by a. emphasizing the need for increased milk intake during pregnancy. b. suggesting she eat more "hot" foods during pregnancy. c. telling her husband that she must increase her intake of fruits and vegetables for the baby's sake. d. suggesting she eat more tofu, bok choy, and broccoli.
ANS: D To increase the intake of calcium and iron in a culturally-appropriate way, the nurse can suggest the woman eat more broccoli and tofu for calcium and to eat more tofu and leafy green vegetables such as bok choy for iron. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 289 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
12. When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a. Increase in baseline variability b. Nonperiodic accelerations c. Early decelerations d. Variable decelerations
ANS: D When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. This is not an expected occurrence after the rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Early declarations are considered reassuring; they are not a concern after rupture of membranes. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 343 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
22. The nurse explains to the expectant mother that which vitamin or mineral can lead to congenital malformations of the fetus if taken in excess by the mother? a. Zinc b. Vitamin D c. Folic acid d. Vitamin A
ANS: D Zinc, vitamin D, and folic acid are vital to good maternity and fetal health and are highly unlikely to be consumed in excess. Vitamin A, taken in excess, causes a number of problems. An analog of vitamin A appears in prescribed acne medications, which must not be taken during pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 266 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
1. Although circumcision continues to be a controversial procedure, many parents in the United States elect to have this surgery performed on their newborn sons. It is believed that newborns do not feel pain; therefore this is the optimum time for the procedure to be done and no anesthesia is required. Is this statement true or false?
ANS: F At one time it was thought that newborns felt no pain. It is now known that pain stimuli pass along the fetal pain pathways as early as the second and third trimester. The nurse who assists with this procedure has a number of options available to reduce the pain response for the neonate. These include a dorsal penile block, EMLA, acetaminophen, and sucrose.
As an adjunct to inductions, a number of procedures to ripen the cervix are employed. One of these methods is the vaginal administration of preparations using prostaglandins. Before administering this medication, the nurse should be aware that this class of drug is an appropriate choice for women who have had a prior cesarean birth. Is this statement true or false?
ANS: F Prostaglandins are contraindicated in patients who have had a prior cesarean birth or other uterine surgery. A side effect of prostaglandin administration is hyperstimulation of the uterus. This may result in reduced uterine blood flow to the fetus, impaired gas exchange, and increased risk of uterine rupture. Prostaglandins should also be used with caution in women who have asthma, heart disease, glaucoma, or renal or hepatic dysfunction.
2. The cultural group in the United States that is most likely to breastfeed are non-Hispanic black women. Is this statement true or false?
ANS: F The cultural group with the lowest breastfeeding rates in the U.S. includes women who are non-Hispanic black. Women who are most likely to breastfeed are Asian, Pacific Islanders, or Hispanic. It is essential that the nurse educates this patient population on the benefits of breastfeeding and provides additional support.
Occasionally a woman arrives at the intrapartum unit ready to give birth. Bearing down, grunting, or stating something like "the baby's coming" should direct the nurse to advise the client, "Do not push, pant, and blow until the physician arrives." Is this statement true or false?
ANS: F The nurse's priority is to prevent or reduce injury to mother and infant if delivery is imminent. The emergency delivery kit should be obtained and preparation made for immediate delivery. An abbreviated assessment should be completed in order to obtain the mother's name, that of the support partner, and her care provider. Estimated date of delivery, allergies, and prenatal care are also important information. If time allows, maternal vital signs should be done, as well as a fetal assessment. After delivery, the priority is to maintain the infant's airway and temperature.
The woman in labor should be encouraged to use the Valsalva maneuver (holding one's breath and tightening abdominal muscles) for pushing during the second stage. Is this statement true or false?
ANS: F The woman should actually be discouraged from using the Valsalva maneuver. This activity increases intrathoracic pressure, reduces venous return, and increases venous pressure. During the Valsalva maneuver, fetal hypoxia may occur. The process is reversed when the woman takes a breath.
1. The nurse has been caring for a primiparous patient who is suspected of carrying a macrosomic infant. Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle's head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary. Is this statement true or false?
ANS: F This is often referred to as the "turtle sign" and is an indication of shoulder dystocia. Delayed or difficult birth of the shoulders may occur if they become impacted above the maternal symphysis pubis. This complication of birth requires immediate intervention because the umbilical cord is compressed and the chest cannot expand within the vagina. Any of several methods may be employed to relieve the impacted shoulders. Shoulder dystocia is unpredictable and although more common in large infants, can occur with a baby of any weight.
2. An important nursing intervention is maintaining safe glucose levels in the newborn. A common practice is to feed infants either breast milk or formula if glucose screening shows results of 40 to 45 mg/dL or less. Is this statement true or false?
ANS: T Glucose water alone is not recommended for newborns because the rapid rise in glucose, will result in increased in sling production, causing a further drop in the blood glucose level. Milk provides a longer-lasting supply of glucose for the newborn.
Pelvic congestion during pregnancy may lead to heightened sexual interest and increased orgasmic experiences. Is this statement true or false?
ANS: T Increased vascularity, edema, and connective tissue changes during pregnancy make the tissues of the vulva and perineum more pliable. This can lead to an increased interest in sexual activity and ease of orgasm.
The birth attendant evaluates whether labor and birth are safer for the woman and her fetus than continuing the pregnancy. The Bishop Scoring System remains a popular tool to assist in this task. Is this statement true or false?
ANS: T The Bishop score uses 5 factors to determine readiness for labor (dilation, effacement, consistency, position, and fetal station). The likelihood of a vaginal birth is similar to that of spontaneous labor if the score is greater than 8.
Pregnancy is a hypercoagulable state, where the mother's blood clots more readily. Is this statement true or false?
ANS: T This is because of an increase in factors that favor coagulation and a decrease in factors that inhibit coagulation. Fibrinogen increases by 50% and factors VII, VIII, IX, and X also rise.
1. At some hospitals in the United States, new mothers are given formula gift packs at discharge. Having been given the gift pack by hospital staff leads parents to believe that formula will be necessary even for breastfeeding mothers. Is this statement true or false?
ANS: T This is the goal of the formula manufacturers, and for this reason many hospitals have stopped providing new mothers with formula gift packs. For many parents, having formula available at home may lead them to feel that having to supplement breastfeeding is necessary. Adding formula to the infant's diet will lessen breastfeeding success because the introduction of supplemental feedings will reduce the amount of breastfeeding time, which in turn will decrease milk production.
A woman who is 8 months' pregnant had a biophysical profile test done. The results give a score of 4/10. The nurse can anticipate that the next plan of action may be to ______________.
ANS: consider delivery A score of 4 out of 10 (4/10) is nonreassuring. Delivery may be considered as an option, because the fetus is at risk.
A woman who is 8 months pregnant has been advised to have an amniocentesis. She asked the nurse the reason for the procedure. The usual reason for an amniocentesis during this period of pregnancy is to determine _________________________.
ANS: fetal lung maturity The usual reason for amniocentesis during the third trimester is to determine fetal lung maturity.
The patient has been diagnosed with hydramnios. When an amniotomy is performed, the nurse is aware that the patient is at risk for which complication? A Placenta previa B Abruptio placentae C Infection D Fetal hypoxia
B Abruptio placentae may occur after an amniotomy if the uterus is distended. Hydramnios will distend the uterus. Placenta previa is not a risk factor associated with hydramnios and/or amniotomy. Infection is a risk factor associated with amniotomy; however, having hydramnios does not increase the risk factor. Fetal hypoxia may occur if abruptio placentae occurs, but it is not a risk factor associated with amniotomy.
A woman is 35 weeks' pregnant during her clinic visit. She complains of numerous vaginal infections during the pregnancy. She tells the nurse, "I'm afraid I have diabetes, because I have some infections." The best response by the nurse would be A. "Diabetes is a possibility. I will set you up for testing." B. "A vaginal infection is a symptom of diabetes, but it also is a problem with normal pregnancies due to the changes in your vaginal area." C. "Itching is a problem with pregnancies and it makes you think you have an infection. The physician can order you some cream to help with the itching and pain." D. "This seems to be a concern with all of our patients today."
B During pregnancy, the glycogen levels of the vaginal area increase. This favors the growth of yeast-causing infections. Diabetes is a possibility, but there are other considerations that need to be assessed first. Vulva itching is not a common problem with pregnancy. These symptoms should be investigated for the cause and treated.
A woman is expecting her first baby in 7 months. During the nurse's assessment Anna continues to ask questions about changes in her body. The nurse can recommend which type of class to assist the woman with her questions? A. Preconception class B. Early pregnancy class C. Childbirth preparation class D. Parenting class
B Early pregnancy class An early pregnancy class focuses on the first two trimesters. They cover information on adapting to pregnancy, dealing with discomforts, and understanding what to expect. Preconception class is for couples thinking about having a baby. They are designed to help them prepare to have a healthy pregnancy. Childbirth preparation class focuses on preparation for labor and delivery. Parenting classes focus on care of the newborn.
In order to monitor for one of the side effects of oxytocin, it is important for the nurse to note the patient's A temperature. B intake and output. C respiratory rate. D deep tendon reflexes.
B Prolonged administration may cause fluid retention. Recording intake and output identifies fluid retention, which precedes water intoxication. Infection, respiratory depression, and alterations in deep tendon reflexes are not a side effect of oxytocin use.
A woman is concerned that she has developed numerous nosebleeds during this pregnancy. She feels this is a sign of leukemia and wants to be screened. The nurse's response to the woman should be based on the fact that A. leukemia is a major concern during pregnancy. B. nosebleeds are a common occurrence during pregnancy. C. nosebleeds are rare in pregnancy; therefore further assessment is necessary. D. platelet count decreases significantly during pregnancy.
B With the higher levels of estrogen causing increased vascularity in the upper respiratory tract, epistaxis is a common occurrence. Leukemia rates do not increase during pregnancy. There is a slight decrease in the platelet count but within normal range.
After seeing the physician, the woman is confused about her upcoming induction. She states to the nurse, "The doctor said I would need a gel inserted prior to going into labor. What does that mean?" The nurse's response should be based on knowledge that A a lubricating gel is inserted prior to induction to facilitate the insertion of the electronic monitoring devices. B a gel is inserted prior to induction to stimulate the rupture of the membranes. C a gel is inserted prior to induction to ripen the cervix. a lubricating gel is inserted so that it will not need to be D reapplied prior to each vaginal exam during labor.
C
What factor is a contraindication for induction of labor? A Post term dates B Maternal hypertension C Previous cesarean section with a classic incision D Fetal death
C A classic incision for a cesarean section is a contraindication for induction of labor. Post term dates, maternal hypertension, and fetal death are indications for induction of labor.
A woman who is 7 months' pregnant states, "I'm worried that something will happen to my baby." The nurse's best response is A. "There is nothing to worry about." B. "The doctor is taking good care of you and your baby." C. "Tell me about your concerns." D. "Your baby is doing fine."
C Encouraging the woman to discuss her feelings is the best approach. The nurse should not disregard or belittle the woman's feelings.
After the use of forceps during labor, the nurse should assess the woman for signs of A bladder distention. B uterine atony. C vaginal lacerations. D deep vein thrombosis.
C Maternal risks include laceration or hematoma of the vagina, perineum, or periurethral area. Bladder distention, uterine atony, and deep vein thrombosis are not effects of forceps.
A woman tells the nurse she is 16 weeks' pregnant. During the assessment, the nurse measures the fundus of the uterus to be at the umbilicus. The nurse correctly interprets the comparison of the dates with the measurements to be A. not comparable. B. congruent. C. incongruent. D. irrelevant.
C The fundus should be at the umbilicus by 20 weeks. At 16 weeks, it is normally midway between the symphysis pubis and the umbilicus. The two sets of data do not match, and more assessment is necessary. From 16 to 18 weeks until 36 weeks, the fundal height, measured in centimeters, is approximately equal to the gestational age of the fetus in weeks.
During prenatal teaching it is important for the nurse to inform the patient about danger signs in pregnancy. Which sign need to be reported immediately to the health care provider? A. Clear mucous vaginal discharge B. Frequent urination C. Vaginal bleeding D. Backache that occurs after standing for a long period
C Vaginal bleeding during pregnancy needs to be reported immediately. It may be an indication of several complications of pregnancy, such as placenta previa or abruptio placenta. Mucous discharge may increase during pregnancy and is considered normal. Frequent urination is common during the first trimester and later in the third trimester. Backaches are the most common complaint during the third trimester.
When preparing a woman for a pelvic examination, the nurse notices that she had undergone a genital mutilation. During the examination, the nurse needs to plan for the woman to A. feel embarrassed because of the mutilation. B. be comfortable with the examination. C. be concerned that a full examination will not be possible. D. experience pain and to make her as comfortable as possible.
D Because the introitus is so small and there is scar tissue that is inelastic, the woman will experience pain with the examination. A full examination may be possible depending on the extent of the mutilation.
While the vital signs of a pregnant woman in her third trimester are being assessed, the woman, who is lying supine, complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? A. Have the patient stand up; retake her blood pressure. B. Have the patient sit down and hold her arm in a dependent position. C. Have the patient lie supine for 5 minutes; recheck her blood pressure on both arms. D. Have the patient turn to her left side; recheck her blood pressure in 5 minutes.
D Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Having the patient stand up would cause an increase in systolic and diastolic pressures. Having the patient hold her arm in a dependent position will cause a false reading.
Internal version might be used to manipulate the A fetus from a breech to a cephalic presentation before labor begins. B fetus from a transverse lie to a longitudinal lie before cesarean birth. C second twin from an oblique lie to a transverse lie before labor begins. D second twin from a transverse lie to cephalic during vaginal birth.
D Internal version is used during vaginal birth to manipulate the fetus into a longitudinal lie (cephalic or breech) that allows it to be born vaginally.
During a prenatal visit at 36 weeks of gestation, the nurse tested a woman's urine for glucose and protein. The results indicated a trace amount of glucose. The nurse's next action should be to A. retest the urine for accuracy. B. have the woman give another sample for retesting. C. report the results immediately to the physician so further testing can be preformed. D. consider this as a normal result for this stage of pregnancy.
D Small amounts of glucose in the urine may indicate physiologic spilling that occurs during normal pregnancy, and further testing is not necessary. Larger amounts of glucose in the urine require further testing.
