Saunders Antepartum and intrapartum ( Maternity )
The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?
1.Rice 2.Cheese 3.Chicken 4.Green, leafy vegetables Correct Answer: 4.Green, leafy vegetables
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 Correct Answer: 1.A change in the uterine contour
The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?
1.A urinary tract infection 2.A single-fetus pregnancy 3.A 26-year-old primigravida 4.A hemoglobin of 13.5 g/dL Correct Answer: 1.A urinary tract infection
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which rationale would the nurse provide to the client for these interventions?
1."Adequate IV fluids and oxygen will stimulate and accelerate the labor process." 2."Administering IV fluids and oxygen will reduce the need for analgesic administration." 3."Providing adequate IV fluids and oxygen during the labor process will minimize the necessity of a cesarean delivery." 4."Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling." Correct Answer: 4."Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling."
During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?
1.80 beats per minute 2.100 beats per minute 3.150 beats per minute 4.180 beats per minute Correct Answer: 3.150 beats per minute
The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?
1.Administer oxygen. 2.Monitor the fetal heart rate. 3.Notify the registered nurse immediately. 4.Place the client in the Trendelenburg's position. Correct Answer: 2.Monitor the fetal heart rate.
A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem do the data best support?
1.Anxiety 2.Low self-esteem 3.High risk for infection 4.Cardiovascular accident (stroke) Correct Answer: 3.High risk for infection
The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?
1.Code cart 2.Suction machine 3.Nasogastric tube 4.Intravenous (IV) supplies Correct Answer: 4.Intravenous (IV) supplies
The nurse is assigned to care for a client experiencing dystocia. Which is the highest priority in planning care?
1.Comfort measures, change of position, and touch 2.Explanations to family members about what is happening in this situation 3.Reinforcement of breathing techniques learned in childbirth preparatory classes 4.Monitoring for changes in the physical and emotional condition of the mother and fetus Correct Answer: 4.Monitoring for changes in the physical and emotional condition of the mother and fetus
The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy?
1.She has a history of chronic hypertension. 2.She is 5 feet, 2 inches tall and weighs 175 pounds. 3.There is a family history of type 1 diabetes mellitus. 4.Her previous two babies were delivered by cesarean section. Correct Answer: 1.She has a history of chronic hypertension.
A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?
1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased blood pressure (BP) monitoring Correct Answer: 2.Increased efficiency of contractions
The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action would the nurse perform first?
1.Explain the reason for these symptoms. 2.Place a cool washcloth on the client's forehead. 3.Measure blood pressure, pulse, and respirations. 4.Place a wedge pillow under the client's right side. Correct Answer: 4.Place a wedge pillow under the client's right side.
The nurse is assisting in the admission of a woman for induction of labor. The nurse would contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.
1.The membranes are ruptured. 2.The fetus is in the breech position. 3.Lesions are present on the perineum. 4.The fetus is not settled into the pelvis. 5.The pregnancy is at 41 weeks' gestation. Correct Answers: 2.The fetus is in the breech position. 3.Lesions are present on the perineum. 4.The fetus is not settled into the pelvis.
The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern?
1.Urinary output has increased. 2.There is no evidence of proteinuria. 3.The client complains of a headache and blurred vision. 4.The blood pressure reading has returned to the prenatal baseline. Correct Answer: 3.The client complains of a headache and blurred vision.
The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse would document which gravida and para status on this client?
1.Gravida I, para I 2.Gravida II, para I 3.Gravida II, para II 4.Gravida III, para II Correct Answer: 2.Gravida II, para I
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?
1."Have either of you ever had surgery?" 2."Do you plan to have any other children?" 3."Do either of you have diabetes mellitus?" 4."Do either of you have problems with high blood pressure?" Correct Answer: 2."Do you plan to have any other children?"
A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids?
1."Hemorrhoids can be gently pushed back inside my body using a lubricant." 2."Diet is very important in the treatment of hemorrhoids. Plenty of liquids and a balance of bulk in the diet are needed." 3."Hemorrhoids are aggravated by standing for long periods. I need to lie down periodically during the day to relieve the pressure." 4."Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born." Correct Answer: 4."Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."
A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?
1."Tell me what concerns you have." 2."Don't worry. Everything will be fine." 3."Why don't you want to have this test done?" 4."The primary health care provider has scheduled this test for a reason." Correct Answer: 1."Tell me what concerns you have."
The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?
1.Weight gain of 25 to 35 pounds 2.Prenatal care beginning at 8 weeks 3.Spontaneous rupture of membranes 2 hours ago 4.History of substance abuse during this pregnancy Correct Answer: 4.History of substance abuse during this pregnancy
A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem?
1.Anxiety and fear 2.Feeling powerless 3.Lack of parenting skills 4.Lack of sensory perception Correct Answer: 1.Anxiety and fear
The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.
1.Legs 2.Vulva 3.Fingers 4.Around the eyes 5.Around the abdomen Correct Answers: 1.Legs 2.Vulva
The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?
1.Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2.Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 3.A cesarean section will be necessary if vaginal lesions are present at the time of labor. 4.Daily administration of acyclovir is necessary during the first trimester of the pregnancy. Correct Answer: 3.A cesarean section will be necessary if vaginal lesions are present at the time of labor.
The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse would tell the client that these exercises are for which purpose?
1.Reduce a backache. 2.Prevent ankle edema. 3.Prevent urinary tract infections. 4.Strengthen the pelvic floor in preparation for delivery. Correct Answer: 4.Strengthen the pelvic floor in preparation for delivery.
The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?
1.Rh incompatibility 2.Fetal cardiomegaly 3.Increase in circulating volume 4.Hypertrophy and increased contractility Correct Answer: 3.Increase in circulating volume
A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client?
1."I am sure your baby will be fine." 2."You will not have any problems if you keep your blood sugar in control." 3."Your baby will need to spend most of the time in the nursery after delivery." 4."Better blood glucose control means fewer effects; let's review your plan of care." Correct Answer: 4."Better blood glucose control means fewer effects; let's review your plan of care."
The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How would the nurse respond to the client? Select all that apply.
1."Leopold's maneuvers are used to determine fetal position." 2."Leopold's maneuvers are used to determine actual fetal heart rate." 3."Leopold's maneuvers are used to determine duration of contractions." 4."Leopold's maneuvers are used to determine frequency of contractions." 5."Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6."Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen." Correct Answers: 1."Leopold's maneuvers are used to determine fetal position." 5."Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6."Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."
The nurse is caring for the nullipara woman in labor. The nurse understands that the primary health care provider must be contacted if which condition becomes apparent?
1..Descent of less than 1 to 2 cm/hr 2.Latent phase of less than 6 hours 3.Decreased periods of uterine relaxation between contractions 4.Dilation of the cervix of greater than 1 and less than 5 cm/hr during the active phase Correct Answer: 3.Decreased periods of uterine relaxation between contractions
The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic would be a part of the teaching plan for this class?
1.Use of over-the-counter medications 2.Fetotoxic substances in the workplace 3.Effects of secondary cigarette smoke on the fetus 4.Travel precautions and use of shoulder seat belts Correct Answer: 4.Travel precautions and use of shoulder seat belts
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta?
1.Wait 5 minutes for placental separation and then pull on the cord. 2.Pull gently on the cord following placental separation as the mother bears down. 3.Place traction on the cord and pull on the placenta as it enters the vaginal canal. 4.Encourage placental separation using forceps, and allow the placenta to deliver spontaneously. Correct Answer: 2.Pull gently on the cord following placental separation as the mother bears down.
Which is the appropriate method to use to deliver the placenta after a precipitate delivery?
1.Wait for approximately 30 minutes and then pull it out. 2.Wrap the cord around a sponge stick and tug upward. 3.Gently guide the placenta out after a spontaneous separation. 4.The nurse's scope of practice does not include delivering the placenta. Correct Answer: 3.Gently guide the placenta out after a spontaneous separation.
The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?
1.The client exhibits no signs of fetal distress. 2.The client expresses an understanding of her condition. 3.The client identifies and uses available support systems. 4.The client demonstrates compliance with activity limitations. Correct Answer: 1.The client exhibits no signs of fetal distress.
A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?
1.The client lacks self-esteem from being ill. 2.The client feels hopeless about the situation. 3.The client is grieving because of her condition. 4.The client lacks knowledge about the disease process. Correct Answer: 2.The client feels hopeless about the situation.
During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding indicates a serious nutritional disorder of pregnancy?
1.Patellar reflex is 2+ 2.Chadwick's sign is positive 3.Ketone bodies in urine are negative 4.Weight compared to last visit is a loss of 2.3 pounds Correct Answer: 4.Weight compared to last visit is a loss of 2.3 pounds
The nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?
1.Potential for infection 2.Inability to tolerate activity 3.Inability to maintain adequate nutritional intake 4.Inability to perform hygiene measures independently Correct Answer: 1.Potential for infection
The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?
1.Primigravidity 2.Shoulder dystocia 3.Hypotonic contractions 4.Weak bearing-down efforts Correct Answer: 2.Shoulder dystocia
The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action?
1.Provide emotional support. 2.Avoid the topic of the disease. 3.Allow the client to be alone if she is crying. 4.Provide all information regarding the disease immediately. Correct Answer: 1.Provide emotional support.
The nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the primary health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?
1.Relieves anxiety for the pregnant client 2.Eliminates the need for further unnecessary screenings 3.Assists in identifying infections that may need to be treated 4.Minimizes the financial cost of caring for an HIV-positive client Correct Answer: 3.Assists in identifying infections that may need to be treated
The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the primary health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?
1.A softening of the cervix 2.The presence of fetal movement 3.The presence of human chorionic gonadotropin in the urine 4.A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus Correct Answer: 1.A softening of the cervix
The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching would the nurse use?
1.Ask about contractions at each visit. 2.Provide a simple pamphlet with multiple illustrations. 3.Palpate for uterine contractions at the same time as the client. 4.Attach the monitor to the client's abdomen and have her palpate at the same time. Correct Answer: 3.Palpate for uterine contractions at the same time as the client.
An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?
1.This approach requires that a vertical skin incision be made. 2.This type of incision allows for extension if a larger incision is needed. 3.This approach is the best choice with a placenta previa on the lower anterior uterine wall. 4.This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy. Correct Answer: 4.This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.
The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms are noted in severe preeclampsia? Select all that apply.
1.Oliguria 2.Seizures 3.Contractions 4.Proteinuria 3+ 5.Muscle cramps 6.Blood pressure 168/116 mm Hg Correct Answers: 1.Oliguria 4.Proteinuria 3+ 6.Blood pressure 168/116 mm Hg
The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
1.Longitudinal lie 2.Minus (-) 1 station 3.Vertex presentation 4.Right occiput anterior (ROA) position Correct Answer: 2.Minus (-) 1 station
The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?
1.Syphilis 2.Age of 45 years 3.Diabetes mellitus 4.Prior history of genital herpes Correct Answer: 1.Syphilis
4.Place a wedge pillow under the client's right side.
1."Maximum level of human chorionic gonadotropin is reached at term." 2."Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3."Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4."Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5."Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning." Correct Answers: 2."Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3."Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4."Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5."Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."
A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.
1.Edema 2.Polyuria 3.Proteinuria 4.Thrombocytopenia 5.Irregular, painless contractions Correct Answers: 1.Edema 3.Proteinuria 4.Thrombocytopenia
The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action is to monitor which criteria?
1.Effacement and dilation of the cervix 2.Frequency, duration, and intensity of contractions 3.The presence of both clear and red vaginal discharge 4.All vital signs, especially heart rate and blood pressure Correct Answer: 4.All vital signs, especially heart rate and blood pressure
The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.
1.Fetus is able to hear (24 weeks). 2.Earliest taste buds present. 3.Kidneys able to secrete urine. 4.Lecithin begins to appear in amniotic fluid (weeks 27-28). 5.Sex can be determined as internal and external organs are sex specific. Correct Answers: 2.Earliest taste buds present. 3.Kidneys able to secrete urine. 5.Sex can be determined as internal and external organs are sex specific.
A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which findings indicate a need to contact the registered nurse (RN)? Select all that apply
1.Hemoglobin of 11 g/dL 2.Blood pressure reading of 144/94 3.Fetal heart rate of 180 beats per minute 4.Maternal pulse rate of 85 beats per minute 5.White blood cell count of 12,000 mm3 Correct Answers: 2.Blood pressure reading of 144/94 3.Fetal heart rate of 180 beats per minute
A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse would monitor this client for which symptom of this complication?
1.High platelet count 2.Oozing from injection sites 3.A reddened rash over the trunk 4.Pain and swelling of the calf of one leg Correct Answer: 2.Oozing from injection sites
The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?
1.Latent phase of 2 hours 2.Descent of 1 cm per hour 3.Decreased periods of uterine relaxation between contractions 4.Dilation of the cervix of 2 to 4 cm per hour during the active phase Correct Answer: 3.Decreased periods of uterine relaxation between contractions
