PN 111-3

3. It may tear a low implanted placenta

A patient arrives in the labor and delivery unit with painless vaginal bleeding. The nurse knows that a vaginal examination is contraindicated because: 1. It may cause an infection. 2. It may stimulate labor contractions. 3. It may tear a low implanted placenta. 4. It may rupture the membranes.

2. Moving into the transition phase of labor

A patient in the active phase of labor begins to experience nausea and has become very irritable. The nurse suspects that the patient is: 1. Going to have a long labor 2. Moving into the transition phase of labor 3. Not satisfied with the nonpharmacological comfort measures 4. Going to require more pain medication

2. Respirations of 10 breaths/minute 4. Urine output of 20 mL in an hour

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply. 1. Proteinuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L (3 mmol/L)

1. Determine the fetal heart rate. When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord.

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1. Determine the fetal heart rate. 2. Prepare for immediate delivery. 3. Monitor the contraction pattern. 4. Note the amount, color, and odor of the amniotic fluid.

1. The placenta has probably just separated from the uterus

A woman had a normal vaginal delivery 7 min ago. The nurse notes that there is a sudden lengthening of the umbilical cord and a gush of blood leaves the vagina. The nurse is aware that: 1. The placenta has probably just separated from the uterus. 2. The woman is beginning to hemorrhage. 3. The woman may have a cervical laceration. 4. The episiotomy requires suturing to stop the bleeding.

4. Being affected by Rh incompatibility

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

2. A manual pelvic examination painless vaginal bleeding is a sign of possible placenta previa. digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client., knowing that which routine labor procedures is contraindicated? 1. Leopold's maneuvers 2. A manual pelvic examination 3. Hemoglobin and hematocrit evaluation 4. External electronic fetal heart rate monitoring

4. Supine position with a wedge under the right hip.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1. Prone position 2. Semi-Fowler's position 3. Trendelenburg's position 4. Supine position with a wedge under the right hip.

1. The status of the patient's immune system 2. If the patient has an infection 3. The patient's blood sugar

A CBC is ordered for a newly admitted labor patient. The nurse knows that this laboratory test provides information regarding: (select all that apply) 1. The status of the patient's immune system 2. If the patient has an infection 3. The patient's blood sugar 4. The patient's blood type and Rh5. If the patient is anemic

2. Betamethasone betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours

A cleint in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rho(D) immune globulin 4. Dinoprostone vaginal insert

3. It is invasive and increases the risk of uterine infection

A disadvantage of internal fetal monitoring is: 1. Accurate information regarding FHR variability is not possible 2. An artifact on the printout is very common 3. It is invasive and increases the risk of uterine infection 4. It cannot provide data about the uterine resting tone.

1. Assess the FHR

A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is: 1. Assess the FHR 2. Check the fluid with Nitrazine paper .3. Notify the health-care provider 4. Note the color of the fluid

3. "I need to call my sister and tell her I'm here."

A patient arrives at the labor and delivery unit in early labor. The nurse expects the following statement from the patient: 1. "I can't stand this pain!" 2. "Leave me alone!" 3. "I need to call my sister and tell her I'm here." 4. "I need the epidural now."

2. "We want to monitor you for signs of infection."

A patient at 37 weeks' gestation is admitted to labor and delivery. Her membranes ruptured 12 hours ago at home. The monitor indicates that the FHR is 150 bpm with moderate variability, no variable or late decelerations, and no uterine contractions. The patient asks the nurse, "Why can't I stay at home until my labor begins?" The best reply by the nurse would be: 1. "It looks like the baby may be experiencing some distress." 2. "We want to monitor you for signs of infection." 3. "Your doctor wants you here." 4. "We can keep you comfortable until labor starts."

2. Massaging the patient's back 3. Discussing the patient's birth plan with the nurse 6. Assisting the patient with breastfeeding

A patient has a doula to support her in labor and immediately after the birth. Which actions are appropriate for the doula? (select all that apply) 1. Assessment of the FHR on the monitor 2. Massaging the patient's back 3. Discussing the patient's birth plan with the nurse 4. Checking for cervical dilation 5. Notifying the health-care provider of labor progress 6. Assisting the patient with breastfeeding 7. Monitoring uterine tone and the amount of bleeding after delivery

4. "Group B strep can cause health problems for the newborn."

A patient is concerned about why the nurse is screening her for GBS. The nurse explains that: 1. "Group B strep is sexually contracted, and we don't want the baby to catch a sexually transmitted infection." 2. "Group B strep can cause you to become very ill during labor." 3. "Group B strep is contagious and we may need to isolate you after delivery." 4. "Group B strep can cause health problems for the newborn."

3. Placental abruption

A patient is experiencing vaginal bleeding and severe abdominal pain. The nurse suspects that the patient is experiencing a: 1. Placenta previa 2. Placenta accreta 3. Placental abruption 4. Placental inversion

3. Assess her blood pressure

A patient is returned to her side-lying position after sitting on the side of the bed for the administration of an epidural. The priority assessment at this time is: 1. Assess for cervical dilation. 2. Assess for numbness of her feet. 3. Assess her blood pressure. 4. Assess her oxygen saturation status.

3. Ask her to breathe into a paper bag.

A patient's membranes ruptured and the contractions have become more intense over the last few minutes. Her blood pressure is 122/80 mm Hg and respiratory rate is 32 bpm. She is 6 cm dilated. She reports a feeling of numbness and tingling of her fingers. Which nursing action is appropriate for this situation? 1. Check the FHR. 2. Turn her to her left side. 3. Ask her to breathe into a paper bag. 4. Recheck her blood pressure.

2. Notify the registered nurse (RN) immediately.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? 1. Monitor the maternal vital signs. 2. Notify the registered nurse (RN) immediately. 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions.

1. Manually elevate the fetal head off the cord. 3. Place the patient in knee-chest position. 5. Apply oxygen via facemask.

After a patient's membranes ruptured, the nurse performs a vaginal examination and notices that the umbilical cord has fallen through the cervix into the vagina. The nurse should: (select all that apply.) 1. Manually elevate the fetal head off the cord. 2. Leave the patient and immediately call the doctor. 3. Place the patient in knee-chest position. 4. Ask the woman to empty her bladder. 5. Apply oxygen via facemask.

1. Support the mother in her reaction to the newborn. Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1. Support the mother in her reaction to the newborn. 2. Encourage the mother to breastfeed soon after birth. 3. Tell the mother that it is important to hold the newborn. 4. Document a complete account of the mother's reaction in the birth record.

1. Naloxone

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Meperidine hydrochloride

1. The patient's blood pressure is greater than 140/90 mm Hg 4. An abnormal or nonreassuring FHR pattern is noted 5. Vaginal bleeding is observed

During the initial assessment in labor and delivery, the health-care provider must be notified immediately if: (select all that apply). 1. The patient's blood pressure is greater than 140/90 mm Hg. 2. The patient is accompanied by five family members. 3. The patient has brought a detailed birth plan to the hospital. 4. An abnormal or nonreassuring FHR pattern is noted. 5. Vaginal bleeding is observed.

1. Offer ice chips 2. Offer a wet washcloth for her lips 4. Offer lip balm

During the transition phase of labor, a patient complains of thirst and dry lips and mouth. Appropriate nursing interventions include: (select all that apply) 1. Offer ice chips. 2. Offer a wet washcloth for her lips. 3. Order a liquid meal tray. 4. Offer lip balm. 5. Inform her that she is about to deliver and afterward she can drink fluids.

1. Determine the position of the fetus

Leopold's maneuvers are performed to: 1. Determine the position of the fetus. 2. Determine the size of the woman's pelvis. 3. Determine the size of the fetus 4. Determine the fundal height

4. The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1. The maneuvers measure the height of the maternal fundus. 2. The maneuvers determine the "lie" and "attitude" of the fetus. 3. The maneuvers are a systematic method for palpating the fetus through the maternal back. 4. The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

4. Peripheral vascular disease

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the primary health care provider (PHCP) who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

2. Blood Pressure

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? 1. Uterine tone 2. Blood Pressure 3. Amount of lochia 4. Deep tendon reflexes

1. Monitoring FHR and contractions 3. Administration of antibiotics if ordered 4. Monitoring the patient's vital signs

Nursing care for patient with PROM includes: (select all that apply) 1. Monitoring FHR and contractions 2. Frequent vaginal cervical examinations 3. Administration of antibiotics if ordered 4. Monitoring the patient's vital signs 5. Placing the patient in knee-chest position

4. "I am giving you a small dose so that the peak effect wears off before the baby is born. That reduces the risk of harm to the baby."

The laboring patient wants medication for pain management. The health-care provider has ordered butorphanol (Stadol) 1 mg IV. The patient asks the nurse if it is safe for the baby. The best response by the nurse is: 1. "Of course it is, trust me! I have been working in this department for 20 years. You'll be glad you took it." 2. "It's such a small dose, I could give it to a 10-year-old. The baby is getting his oxygen through the umbilical cord." 3. "Don't worry, the baby will be fine. My goal is help you have a safe labor and I am watching out for your baby." 4. "I am giving you a small dose so that the peak effect wears off before the baby is born. That reduces the risk of harm to the baby."

2. Keep the client in a side-lying position.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1. Prepare for an oxytocin infusion. 2. Keep the client in a side-lying position. 3. Prepare the client for epidural anesthesia. 4. Encourage the client to start pushing with the contractions.

4. Determine the maternal and fetal vital signs.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? 1. Estimate the fetal size. 2. Check pelvic adequacy. 3. Administer the analgesic. 4. Determine the maternal and fetal vital signs.

2. Uterine tenderness on palpation vaginal bleeding in a pregnant client is most often caused by placenta previa or placental abruption. uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding? 1. Soft abdomen on palpation 2. Uterine tenderness on palpation 3. No complaints of abdominal pain 4. Lack of uterine irritability or tetanic contractions

1. Baseline fetal heart rate

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1. Baseline fetal heart rate 2. Intensity of contractions 3. Maternal blood pressure 4. Frequency of contractions

1. A change in the uterine contour

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1. A change in the uterine contour 2. Sudden and sharp abdominal pain 3. A shortening of the umbilical cord 4. A decrease in blood loss from the introitus

3. Turn the client onto her side.

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 1. Monitor the urinary output. 2. Monitor the maternal pulse. 3. Turn the client onto her side. 4. Monitor the maternal blood pressure.

1. Nausea 3. Drowsiness 5. Decreased respiratory rate

The nurse is aware that a common side effect(s) of IV opioid anesthesia is (are): (select all that apply). 1. Nausea 2. Unable to urinate 3. Drowsiness 4. Unable to feel the urge to push 5. Decreased respiratory rate

2. Side-lying Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her side. Squatting, tailor sitting and semi-fowler's position are incorrect because they would not prevent hypotension.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1. Squatting 2. Side-lying 3. Tailor sitting 4. Semi-Fowler's

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

2. Apply an FSE

The nurse is having difficulty obtaining information on the fetal monitor regarding the variability of the FHR. The nurse knows that the best plan of action is to: 1. Turn the woman to her side. 2. Apply an FSE 3. Apply oxygen via face mask. 4. Prepare the woman for delivery.

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should case the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate

2. Intratracheal

The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2. Turn the patient to her side 3. Apply oxygen via face mask

The nurse notes on the fetal monitor that the fetus is experiencing a late deceleration. Which nursing actions are appropriate in this situation? (select all that apply) 1. Continue to observe the fetal monitor for three more contractions 2. Turn the patient to her side 3. Apply oxygen via face mask 4. Increase the oxytocin to speed up labor.5. Assist the patient into a pushing position

4. "I would like to show you how to help her relax."

The nurse notices that the patient's husband is very engrossed in watching the football game on the television. The patient has progressed into the active phase of labor. Which approach by the nurse is the most appropriate for involving the husband in the labor care? 1. "You need to turn that TV off and help your wife." 2. "Did you ask your wife if she wants to watch the game?" 3. "Did you take childbirth classes together?" 4. "I would like to show you how to help her relax."

1. "I will flush the eyes after instilling the ointment."

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."

B. 30 minutes

When caring for a patient is in active labor The patient's Vital Signs should be assessed every A. 15 minutes B. 30 minutes C. 1 hour D. 2 hours

1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood 3. Fundus is boggy following separation 4. Change from globular to discoid shape 5. Fetal membranes are seen at the introitus

1. Multiple gestation 2. Urinary tract infection 4. Bacterial vaginosis

Which of the following are risk factors for preterm labor? (select all that apply) 1. Multiple gestation 2. Urinary tract infection 3. Rh negative mother 4. Bacterial vaginosis 5. A previous spontaneous abortion (i.e., miscarriage)

1. A bulging perineum 2. The mother stating a desire to push 4. Increases in bloody show and mucus

Which of the following are signs of an imminent precipitous delivery? (select all that apply.) 1. A bulging perineum 2. The mother stating a desire to push 3. Nausea and vomiting 4. Increases in bloody show and mucus 5. Contractions that are 3 min apart and strong

2. A multigravida, scheduled for her fourth Cesarean birth

Which of the following patients is at highest risk for uterine rupture? 1. A 15-year-old primigravida with a large fetus 2. A multigravida, scheduled for her fourth Cesarean birth 3. A primigravida pregnant with triplets 4. A multigravida delivering her second child in 2 years

3. A patient with a post-term pregnancy 4. A patient with a preterm pregnancy

Which of the following patients should receive continual fetal monitoring in labor? (select all that apply). 1. A patient with a hypertensive disorder 2. A patient delivering her first baby 3. A patient with a post-term pregnancy 4. A patient with a preterm pregnancy 5. A patient with a positive GBS test

3. The primigravida who abuses cocaine

Which of the following patients will the nurse monitor carefully for signs of placental abruption? 1. The multigravida, giving birth for the fifth time 2. The multigravida who is 30 weeks' gestation 3. The primigravida who abuses cocaine 4. The primigravida who is 22 years old

4. The fetus may be small for gestational age.

Which of the following statements regarding oligohydramnios is true? 1. There will be at least 1500 mL of amniotic fluid. 2. Throughout the pregnancy, the placenta is the chief source of amniotic fluid. 3. The patient may experience a post-term pregnancy. 4. The fetus may be small for gestational age.

1. The primigravida who is a diabetic

Which pregnant patient is at greatest risk for macrosomia? 1. The primigravida who is a diabetic 2. The multigravida who is Rh negative 3. The primigravida who abuses alcohol 4. The multigravida who worked as a hair stylist