crash review

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: A) Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts. B) Telling the woman to start pushing as soon as her cervix is fully dilated. C) Stopping the epidural anesthetic so the woman can feel the urge to push and thereby push more effectively D) Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

A) Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts.

Which of the following is true about labor dystocia. A) Labor dystocia would be defined if it took longer than an hour to dilate 1 cm during active labor in a first time laboring woman. B) In a nulliparous women with an arrest of labor, the use of pitocin will only help about 25% of women achieve a vaginal birth. C) second stage is abnormally long if it takes longer than 1 hour in a first time mother. D) When a woman has weak and infrequent contractions it is an indication that the baby is too large and she needs to have a Cesarean soon.

A) Labor dystocia would be defined if it took longer than an hour to dilate 1 cm during active labor in a first time laboring woman.

On examination, it is noted that a full-term primipara in active labor is right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

ANS: 3 1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines. 2. The fetal head is well past engagement. Engagement is defined as 0 station. 3. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away. 4. External rotation does not occur until after delivery of the fetal head.

A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.

ANS: 3 1. Oxytocin is safe to administer if a client has preeclampsia. 2. The frequency is within normal limits. 3. The duration of the contractions is prolonged. The baby will be deprived of oxygen. 4. The FH is within normal limits

The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?

A diet that is high in fluids and fiber to decrease constipation

upon entering the room of a client who has had a spontaneous abortion, the observes the client crying. Which response but the nurse would be most appropriate? A. why are you crying? b. a baby still wasn't formed in your uterus c. I'm sorry you lost your baby d. all a all help your pain

c

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? (Note: see power point on complications of Labor for homework part 1 on preterm labor) A) Estriol is not found in maternal saliva. B) Irregular, mild uterine contractions are occurring every 12 to 15 minutes C) Fetal fibronectin is present in vaginal secretions. D) The cervix is effacing and dilated to 2 cm.

D) The cervix is effacing and dilated to 2 cm.

a nurse is preparing a teaching program for a group of pregnant women about preventing infection during pregnancy. when describing measures for preventing cytomegalovirus infection, which measure would the nurse most likely include? a. antibody titer screening b. frequent hand washing c. immunization d. prenatal screening

b

A client at 10 weeks gestation comes to the clinic for a prenatal follow-up. The client reports experiencing morning sickness. She states, "It happens at any time of the day. Is there anything I can do?" Which suggestions by the nurse would be most helpful? Select all that apply.

"Try eating some dry crackers before you getting out of bed in the morning." "Avoid any strong food odors as much as possible." "Limit your intake of fluids when you eat your meals."

Match the degree of tear or episiotomy to its description A. Laceration that goes through the anal sphincter and the rectal wall B. a tear through part or all of the perineal muscles C. small nick in the perineum, not involving muscle D. Laceration through part or all of anal sphincter muscle 1st degree 2nd degree 3rd degree 4th degree

1st degree = C. small nick in the perineum, not involving muscle 2nd degree = B. a tear through part or all of the perineal muscles 3rd degree = D. Laceration through part or all of anal sphincter muscle 4th degree = A. Laceration that goes through the anal sphincter and the rectal wall

The nurse determines that a client's placenta has separated during the third stage of labor. Which clinical finding supports the nurse's conclusion? A gush of blood Bogginess of the uterus Shrinkage of the uterus An abrupt drop in blood pressure

A gush of blood

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take? A) Call for help and Notify the care provider immediately B) Start pitocin C) Have her empty her bladder D) Insert a Foley catheter

A) Call for help and Notify the care provider immediately

In evaluating the effectiveness of oxytocin induction, the nurse would expect: A) Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart. B) Labor to progress at least 2 cm/hr dilation. C) At least 30 mU/min of oxytocin will be needed to achieve cervical dilation D) The intensity of contractions to be at least 110 to 130 mm Hg.

A) Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: A) Counterpressure against the sacrum B) Pant-blow (breaths and puffs) breathing techniques C) Effleurage. D) Conscious relaxation or guided imagery.

A) Counterpressure against the sacrum

What is the correct order of the cardinal movements? A.Extension B.Internal Rotation C.Expulsion D.Engagement, Flexion Descent E.External Rotation A) D, B, A, E, C B) D, A, B, E, C C) B, D, A, C, E D) D, B, A, C. E

A) D, B, A, E, C p. 388-389

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? Select all that apply. A) Decreased urinary output and irritability B) Transient headache and +1 proteinuria C) Ankle clonus and epigastric pain D) Platelet count of less than 100,000/mm3 and visual problems E) Seizure activity and hypotension

A) Decreased urinary output and irritability C) Ankle clonus and epigastric pain D) Platelet count of less than 100,000/mm3 and visual problems RATIONAL: A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.

A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, "I'm so thirsty and warm." The nurse: A) Discontinues the magnesium sulfate infusion. B) Administers oxygen. C) Calls for a stat magnesium sulfate level. D) Prepares to administer hydralazine.

A) Discontinues the magnesium sulfate infusion.

To adequately care for a laboring woman, the nurse knows that which stage of labor varies the most in length? A) First B) Fourth C) Third D) Second

A) First p. 387-388

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 175/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A) Hydralazine. B) Magnesium sulfate bolus. C) Diazepam. D) Calcium gluconate.

A) Hydralazine.

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _____ has increased. A) Intrauterine infection B) Hemorrhage C) Precipitous labor D) Supine hypotension

A) Intrauterine infection

A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? A) Meperidine (Demerol) B) Promethazine (Phenergan) C) Butorphanol tartrate (Stadol) D) Nalbuphine (Nubain)

A) Meperidine (Demerol)

A primiparous woman is in the triage room being evaluated for labor. She has been having contractions for 2 days, has slept little and is feeling exhausted. On cervical exam she is 1.5 cm dilated, 50% effaced, -1 station - which is not changed from a day ago. Contractions are irregular, 30-40 secs long. Which of the following is the best option for her? A) Offer morphine IM, and a sedative to help her sleep. B) Admit her and give her an epidural. C) Tell her to go home, relax D) Give her a couple of seconal to help her sleep.

A) Offer morphine IM, and a sedative to help her sleep.

For a woman at 42 weeks of gestation, which finding would require more assessment by the nurse? A) One fetal movement noted in 1 hour of assessment by the mother B) Fetal heart rate of 116 beats/min C) Cervix dilated 2 cm and 50% effaced D) Score of 8 on the biophysical profile

A) One fetal movement noted in 1 hour of assessment by the mother

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: A) Placental abruption. B) Rupture of the uterus. C) Placenta previa. D) Eclamptic seizure.

A) Placental abruption.

Which basic type of pelvis includes the correct description and percentage of occurrence in women? A) Platypelloid: flattened, wide, shallow; 3% B) Anthropoid: resembling the ape; narrower; 10% C) Android: resembling the male; wider oval; 15% D) Gynecoid: classic female; heart shaped; 75%

A) Platypelloid: flattened, wide, shallow; 3% p. 383

Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance A) Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. B) In the United States early in this century, preterm birth accounted for 18% to 20% of all births. C) Low birth weight is anything below 3.7 pounds. D) The terms preterm birth and low birth weight can be used interchangeably.

A) Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.

What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. B) Perform a vaginal examination, reposition the mother, and provide oxygen via face mask. C) Administer oxygen to the mother, increase IV fluid, and notify the care provider. D) Call the provider, reposition the mother, and perform a vaginal examination

A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.

In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? A) Serum magnesium level of 10 mg/dl B) Respiratory rate of 16 breaths/min C) Deep tendon reflexes 2+ and no clonus D) Urine output of 160 ml in 4 hours

A) Serum magnesium level of 10 mg/dl

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to: A) Stay with the client and call for help. B) Insert an oral airway. C) Administer oxygen by mask. D) Suction the mouth to prevent aspiration.

A) Stay with the client and call for help.

A woman arrive in the admission area of L&D. She is complaining of severe abdominal pain which she thinks are contractions and vaginal bleeding. You notice the sheet on the bed is about 1/3 covered with port wine fluid. You would do all of the following EXCEPT: A) Take a complete medical history and measure her vital signs. B) Position on her side and give her oxygen if the fetal heart rate was category II. C) NOtify the charge nurse and patient's provider. D) Start an IV E) Put her on the monitor

A) Take a complete medical history and measure her vital signs.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: A) The placenta has separated. B) A cervical tear occurred during the birth C) The woman is beginning to hemorrhage. D) Clots have formed in the upper uterine segment.

A) The placenta has separated.

With regard to a woman's intake and output during labor, nurses should be aware that: A) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor. B) Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. C) Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. D) When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly

A) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor.

The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by: A) Umbilical cord compression. B) Altered fetal cerebral blood flow C) Fetal hypoxemia. D) Uteroplacental insufficiency

A) Umbilical cord compression. p. 432

On review of a fetal monitor tracing, the nurse notes that for several contractions the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: A. Describe the finding in the nurse's notes. B. Reposition the woman onto her side. C. Call the physician for instructions. D. Administer oxygen at 8 to 10 L/min with a tight face mask.

A. Describe the finding in the nurse's notes. RATIONAL: An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix.

A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.

ANS: 1 1. Because the client will have a cesarean section with anesthesia, the woman should be taught coughing and deepbreathing exercises for the postoperative period. 2. Because the woman will not be going through labor, it is inappropriate to teach her about the phases of the first stage of labor. 3. Because the woman will not be going through labor, it is inappropriate to teach her about Lamaze breathing techniques. 4. Because the woman will not be going through labor, it is inappropriate to teach her about Leboyer hydrobirthing.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

ANS: 1 1. Fundal heights increase during pregnancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour. 2. Pain-free vaginal bleeding is consistent with a diagnosis of placenta previa. 3. The nurse would expect to see late fetal heart decelerations. 4. This is not an infectious state. The nurse would not expect to see hyperthermia.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min s 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

ANS: 1 1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip. 2. Oxygen should be administered, but the mask should be put on after the oxytocin has been turned off. 3. Repositioning is indicated, but should be performed after the oxytocin has been turned off. 4. The obstetrician should be called, but after the oxytocin has been turned off.

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

ANS: 1 and 3 are correct. 1. This is a sign of placental separation. 2. Once second stage is complete, the baby is no longer in utero. 3. This is a sign of placental separation. 4. Dilation and effacement are complete before second stage begins. 5. Rectal pressure is usually a sign of fetal descent. Once the second stage is complete, the baby is no longer in utero

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

ANS: 1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 3. Expelling the mucous plug is not sufficient reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconiumstained fluid. The client needs to be assessed. 5. The latent phase of labor can last up to a full day. In addition, Braxton Hicks' contractions can last for quite a while. Even though a woman may feel cramping for 4 hours or more, she may not be in true labor.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

ANS: 1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates progression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 3. The amniotic sac can rupture at any time. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The gravida's ability to work with her labor is more dependent on her level of pain and her preparation for labor than on the phases and/or stages of labor.

The nurse in the obstetrician's office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day.

ANS: 1, 2, and 5 are correct. 1. This client is high risk for PTL because she is over 35 years of age and in an abusive relationship. 2. A previous preterm delivery places a client at increased risk of preterm labor. 3. The presence of a two-vessel cord does not place a client at increased risk of preterm labor. 4. A history of long menstrual periods does not place a client at increased risk of preterm labor. 5. A woman who smokes cigarettes is at high risk for preterm labor.

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.

ANS: 1, 2, and 5 are correct. 1. When a baby is in the breech presentation, there is increased risk of prolapsed cord. 2. The presenting part is floating, which increases the risk of prolapsed cord. 3. With decreased quantity of amniotic fluid there is no increased risk of prolapsed cord. 4. 2-cm dilation is not a situation that is at high risk for prolapsed cord. 5. When a baby is in the transverse lie, there is increased risk for prolapsed cord.

A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.

ANS: 1, 4, and 5 are correct. 1. The client's hepatitis B status should be assessed. 2. The client's rubeola status is not immediately important. 3. The client's varicella status is not immediately important. 4. The client's group B streptococcus status should be assessed. 5. The client's HIV/AIDS status should be assessed.

The nurse is monitoring a woman, G2 P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; -3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; -3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1. Labor is progressing well. 2. The woman is likely carrying a macrosomic fetus. 3. The baby is in fetal distress. 4. The woman will be in second stage in about five hours.

ANS: 2 1. Although dilation is progressing, the station is unchanged. The baby, therefore, is not descending into the birth canal. The nurse cannot conclude that the labor is progressing well. 2. Because the presenting part is not descending into the birth canal, the nurse can logically conclude that the baby is macrosomic. 3. There is no sign of fetal distress in this scenario. 4. This woman is a multigravida. The average length of the transition phase of labor for multiparas is 10 minutes.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate.

ANS: 2 1. Although this client is light-headed, her problem is unlikely related to her blood pressure. 2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. 3. It is unnecessary for this client to be moved to her side. 4. The baby is not in jeopardy at this time.

An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes s 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.

ANS: 2 1. As long as oxytocin is increased slowly and the contraction pattern and fetal response are monitored carefully, there is no absolute, unsafe maximum dosage of oxytocin. 2. The practitioner should increase the dosage of oxytocin at a minimum time interval of every 30 minutes. 3. Although postdates babies are higher risk for fetal distress, it is not contraindicated to induce with oxytocin. 4. A 60-second contraction duration is normal. TEST-TAKING TIP: The half-life (the time it takes half of a medication to be metabolized by the body) of oxytocin is relatively long— about 15 minutes. And at least 3 half-lives usually elapse before therapeutic responses are noted. Increasing the infusion rate too rapidly, therefore, can lead to hyperstimulation of the uterine muscle and consequent fetal distress.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

ANS: 2 1. Engagement is achieved when the baby's presenting part reaches an imaginary line between the ischial spines. The station of the fetal head, as described in the question, is past the inlet. 2. The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis. 3. The baby is physiologically unable to enter the true pelvis when in a horizontal lie. 4. The attitude of the baby is not discussed in the ultrasound statement.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.

ANS: 2 1. Frequency and duration are important, but they are not the highest priority at this time. 2. Maternal temperature is the highest priority. 3. Cervical change is important, but it is not the highest priority at this time. 4. Maternal pulse rate is important, but it is not the highest priority at this time.

A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.

ANS: 2 1. Human papillomavirus is not an indication for cesarean section. 2. Standard precautions are indicated in this situation. 3. A baby born to a woman with HPV receives standard care in the well-baby nursery. 4. HPV is not airborne. A mask is not required. TEST-TAKING TIP: Although HPV is a sexually transmitted infection and it can in rare instances be contracted by the neonate from the mother, the Centers for Disease Control and Prevention do not recommend that cesarean section be performed merely to prevent vertical transmission of HPV

An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.

ANS: 2 1. Hypertension is not related to the diagnosis of placenta accreta. 2. The nurse would expect the woman to hemorrhage. 3. Bradycardia is not related to the diagnosis of placenta accreta. 4. Hyperthermia is not related to the diagnosis of placenta accreta.

A full-term client, contracting every 15 min s 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.

ANS: 2 1. Intermittent fetal heart auscultation is appropriate at this time. 2. Vaginal examination is contraindicated. 3. Intravenous fluid administration is appropriate at this time. 4. Nipple stimulation is appropriate at this time. TEST-TAKING TIP: The client in this scenario is at risk of an ascending infection from the vagina to the uterine body because she has prolonged rupture of membranes. Any time a vaginal examination is performed, the chance of infection rises. Nipple stimulation is appropriate because endogenous oxytocin will be released, which would augment the client's weak labor pattern.

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

ANS: 2 1. Intravenous oxytocin administration is inappropriate. This would cause the uterus to contract markedly but would not assist with the delivery of the fetal shoulders. 2. Flexing the woman's hips sharply toward her abdomen, called McRoberts' maneuver, is appropriate. 3. Oxygen administration will not assist with the delivery of the fetal shoulders. 4. Fundal pressure is inappropriate.

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.

ANS: 2 1. It is inappropriate to discourage a laboring client from taking pain medication simply because she has abused drugs. 2. The nurse should notify the health care practitioner of the client's request. 3. Substance abuse is not a contraindication for analgesic medication in labor. 4. Although the client may benefit from labor breathing, she has requested pain medication and that request should be acted upon

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

ANS: 2 1. The client may have a urinary tract infection with blood in the urine. First, however, the nurse should acknowledge the client's concerns. 2. The nurse is using reflection to acknowledge the client's concerns. 3. Although the woman's statement is consistent with the expulsion of the mucous plug, this response ignores the fact that the client is frightened by what she has seen. 4. The nurse will want to clarify that the woman isn't actually bleeding, but the question should follow an acknowledgment of the woman's concerns.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

ANS: 2 1. The woman should not push until the next contraction. She should be allowed to sleep at this time. 2. The woman's privacy should be maintained while she is resting. 3. The woman is in no apparent distress. Vital sign assessment is not indicated. 4. The woman is in no apparent distress. Oxygen is not indicated.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

ANS: 2 1. This comment would be consistent with a client in the latent phase of labor. 2. This comment is consistent with a woman in the transition phase of stage 1. 3. This comment could be made at a variety of times during the labor. 4. This comment is consistent with a woman in stage 2 labor.

The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 130 seconds. 4. Attitude flexed.

ANS: 2 1. Uterine hyperstimulation can be seen with moderate intensities. 2. A frequency pattern of every 3 minutes is ideal. 3. A duration of 130 seconds is indicative of tachysystole. 4. The attitude of the baby has nothing to do with hyperstimulation.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions is recommended prior to performing this assessment? 1. Place the client in the lateral recumbent position. 2. Insert an internal fetal monitor electrode. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

ANS: 2 1. When assessing the variability of the fetal heart, the mother can be in any position. 2. Before the variability can be accurately assessed, an internal fetal heart electrode should be applied. 3. Only after assessing a poor fetal monitor tracing would the nurse administer oxygen. 4. Variability is unrelated to fetal movement.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

ANS: 2 1. With pain and increased energy needs, the pulse rate often increases. 2. The blood pressure rises dramatically. 3. Although the woman is working very hard, her temperature should remain normal. 4. With pain and increased energy needs, the respiratory rate often increases.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min s 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

ANS: 2 1. Women may contract without being in true labor. 2. Once the cervix begins to dilate, a client is in true labor. 3. Membranes can rupture before true labor begins. 4. Engagement can occur before true labor begins.

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

ANS: 3 1. The maternal blood pressure is not the priority assessment after an amniotomy. 2. The maternal pulse is not the priority assessment after an amniotomy. 3. It is essential to assess the fetal heart rate immediately after an amniotomy. 4. Fetal fibronectin is assessed during pregnancy. It is not assessed once a woman enters labor.

The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal, warranting further sampling. 4. The results are within normal limits.

ANS: 3 1. The results are equivocal; therefore, the nurse cannot conclude that the baby is severely acidotic. 2. Practitioners usually will repeat the test a few minutes after an equivocal result. 3. Further testing is indicated. 4. The results are not within normal limits. TEST-TAKING TIP: Some practitioners perform fetal scalp sampling when there is a decrease in fetal heart variability. A normal fetal pH is defined as 7.25 to 7.35. An acidotic fetus has a pH that is less than 7.20. When the pH is between 7.20 to 7.25, the value is considered to be equivocal with a need for further testing. Usually interventions are instituted—oxygen applied, position changed, IV fluid increased—and another sampling is done in 10 to 15 minutes.

The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL. 2. G2 P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2 P1001, 39 weeks, Rh-negative, today's hematocrit 31%

ANS: 3 1. Although placenta previa is an obstetric complication, the hemoglobin is within normal limits. 2. Although diabetes mellitus is an obstetric complication, the blood glucose is within normal limits. 3. A placental abruption is a life-threatening situation for the fetus. It has been 15 minutes since the fetal heart was assessed. This is the nurse's priority. 4. A woman who is Rh-negative may or not may not be carrying a baby who is Rhpositive. Either way, a hematocrit of 31%, although low, is not an emergent value.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

ANS: 3 1. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed in the LUQ. 2. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed LLQ. 3. Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. 4. The monitor electrode should have been placed in the RLQ if the nurse had assessed a vertex presentation.

A woman being induced with oxytocin (Pitocin) is contracting every 3 min s30 seconds. Suddenly the woman becomes dypsneic and cyanotic, and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.

ANS: 3 1. Blood pressure assessment is important, but it is not the priority action. 2. FH assessment is important, but it is not the priority action. 3. The nurse's priority action is to administer oxygen. 4. It is appropriate to stop the infusion, but that is not the priority action.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

ANS: 3 1. Breathing will help with contraction pain, but is not as effective when a client is experiencing back labor. 2. It is inappropriate automatically to encourage mothers to have anesthesia or analgesia in labor. There are other methods of providing pain relief. 3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head. 4. Hydrotherapy is very soothing but will not provide direct relief.

A preterm labor client, 30 weeks' gestation, who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."

ANS: 3 1. Decadron is not a tocolytic. 2. Decadron is not an anti-infective. 3. Decadron is a steroid that hastens the maturation of the fetal lung fields. 4. Decadron is not an analgesic.

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min s 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

ANS: 3 1. Oxytocin will increase the client's contractions. The administration of this medication is inappropriate at this time. 2. Methergine should never be administered unless the placenta is already delivered. 3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time. 4. Morphine sulfate is an opioid. There is no rationale for its administration in the scenario.

The childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

ANS: 3 1. The alternate pant-blow technique is used during stage 1 of labor. 2. Rhythmic, shallow breaths are used during stage 1 of labor. 3. Open glottal pushing is used during stage 2 of labor. 4. Slow chest breathing is used during stage 1.

The health care practitioner performed an amniotomy 5 minutes ago on a client, G3 P1011, 40 weeks' gestation, -4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is post-term. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.

ANS: 3 1. The fetus is full-term. Post-term is defined by most texts as 42 weeks' gestation or later and by some as 41 weeks' gestation or later. 2. The fetus is not breech; it is vertex. 3. It is likely that the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelerations are seen on the FH monitor. 4. If the client were infected, the amniotic fluid would be foul smelling.

A nurse is caring for a gravid client who is G1 P0000, 35 weeks' gestation. Which of the following would warrant the nurse to notify the woman's health care practitioner that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.

ANS: 3 and 4 are correct. 1. The presence of contractions without cervical change is not diagnostic of preterm labor. 2. Preterm labor is defined as cervical effacement of greater than 80%. Although the client has effaced slightly, a diagnosis of preterm labor cannot as yet be made. 3. The dilation of 3 cm is indicative of preterm labor. 4. A cervical length of 2 cm is indicative of preterm labor. 5. The presence of 30-second-duration contractions is not diagnostic of preterm labor.

The nurse is assessing the Bishop score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.

ANS: 3, 4, and 5 are correct. 1. Gestational age is not part of the Bishop score. 2. The status of the membranes is not part of the Bishop score. 3. Cervical dilation is part of the Bishop score. 4. Fetal station is part of the Bishop score. 5. Cervical position is part of the Bishop score.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

ANS: 3, 4, and 5 are correct. 1. Hypnotic suggestion is usually not included in childbirth education based on the Lamaze method. 2. Rhythmic chanting is usually not included in childbirth education based on the Lamaze method. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education.

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 g/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30

ANS: 4 1. Oxygen saturations are noninvasive assessments whereas fetal scalp sampling assessments are performed on blood obtained from the fetal scalp. Fetal oxygen saturation levels are well below those seen in extrauterine life—approximately 50% to 75%. 2. Normal fetal hemoglobin levels are well above those seen in extrauterine life—14 to 20 g/dL. 3. This fetal glucose level is indicative of maternal hyperglycemia. 4. This fetal pH value is within normal limits.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

ANS: 4 1. This client is fully dilated and effaced, but the baby is not yet engaged. Until the baby descends and stimulates rectal pressure, it is inappropriate for the client to begin to push. 2. Fundal pressure is inappropriate. 3. Many women push in the squatting position, but it is too early to push at this time. 4. Monitoring for rectal pressure is appropriate at this time. TEST-TAKING TIP: Although the test taker may see in practice that women are encouraged to begin to push as soon as they become fully dilated, it is best practice to wait until the woman exhibits signs of rectal pressure. Pushing a baby that is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord.

A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.

ANS: 4 1. Although the blood glucose of a client with diabetes is important, it can wait. 2. Although the vaginal blood loss assessment of a client who has had a spontaneous abortion is important, it is usually minimal. This client can wait. 3. It is important to assess the patellar reflexes of a client with preeclampsia, but with mild disease, that action can wait. 4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.

ANS: 4 1. Hyperreflexia is seen with severe preeclampsia. The magnesium sulfate is being administered to depress the hyperreflexia. 2. 30 mL/hr is an acceptable urinary output. 3. A respiratory rate of 16 rpm is within normal limits. 4. A serum magnesium level of 9 g/dL is dangerously high. The health care practitioner should be notified.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing

ANS: 4 1. It is inappropriate to encourage her to have an epidural at this time. 2. It is inappropriate to encourage her to have an IV analgesic at this time. 3. A change of position might help but will probably not be completely effective. 4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.

The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.

ANS: 4 1. Oxygen administered during labor should be delivered via a tight-fitting mask at 8 to 10 liters per minute. 2. The client should be positioned on her side or in Trendelenburg position. 3. The best way to monitor the fetus is with an internal electrode. 4. Increasing the IV rate helps to improve perfusion to the placenta.

A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.

ANS: 4 1. The woman does have a legal right not to sign the form. To badger her about her decision is inappropriate. 2. Practitioners who perform surgery on a client who has refused to sign a consent form can be arrested for assault and battery. 3. It is inappropriate to scare a patient into submission. 4. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

ANS: 4 1. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. 2. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. 3. Although this client is fully dilated, the cervix is not fully effaced and the baby has not descended far enough. 4. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual odor." 3. "Your labor should start very soon." 4. "Have you felt the baby move since the membranes broke?"

ANS: 4 1. This comment is inappropriate. The nurse should ask the woman whether or not she has felt fetal movement. 2. The amniotic fluid smells musty but it does not naturally have an offensive smell. 3. This statement is likely true but the nurse should ask the woman whether or not she has felt fetal movement and the woman should be advised to go to the hospital for evaluation. 4. The most important information needed by the nurse should relate to the health and well-being of the fetus. Fetal movement indicates that the baby is alive.

A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 3 min s 90 sec to q 2 min s 60 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.

ANS: 4 and 5 are correct. 1. A decrease in the frequency of the contractions from q 3 min s90 sec to q 2 min s60 is the expected, therapeutic response. This change does not warrant stopping the medication. 2. A change in fetal heart rate pattern from no decelerations to early decelerations is a benign change. This change does not warrant stopping the medication. 3. Minimal variability is a sign of poor fetal oxygenation, whereas moderate variability is a sign of good fetal oxygenation. This change does not warrant stopping the medication. 4. When the fetal heart rate pattern is greater than 200 bpm, the medication should be stopped. 5. Terbutaline is contraindicated when the membranes have ruptured prematurely.

A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding? Placenta previa Tubal pregnancy Abruptio placentae Spontaneous abortion

Abruptio placentae

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows moderate short-term & long-term variability with a baseline of 142 beats/minute. What should the nurse do? a. Provide caring labor support b. Administer oxygen via face mask c. Change the client's position d. Increase the client's IV rate

Answer A - The baseline fetal heart variability is one of the most important fetal heart assessments. If the fetus' heart rate shows moderate variability, the nurse can assume that the fetus is not hypoxic or acidotic.

The L&D nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left & small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which position is consistent with these findings? a. Left occipital anterior (LOA) b. Left sacral posterior (LSP) c. Right mentum anterior (RMA) d. Right sacral posterior (RSP)

Answer A - The fetal back ("flat object") is felt on the mother's left side, the "small objects" are felt on her right side, the buttocks ("soft round mass") are felt in the fundal region, & the head ("hard round mass) is felt above her symphysis.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which action by the nurse is appropriate? a. Inform the client that the fetal heart rate is normal. b. Reassess in 5 minutes to verify the results. c. Immediately report the rate to the health care provider. d. Place the client on her left side & apply oxygen by face mask.

Answer A - The normal fetal heart rate range is 110-160 beats/min. A rate of 152, therefore is within normal limits. No further action is needed at this time.

Which actions would the nurse expect to perform immediately before a client is to have an epidural placed for labor pain management? (Select all that apply.) a. Assess FHR b. Infuse 1000cc of LR c. Place the client in Trendelenburg position d. Monitor blood pressure every 5 minutes for 15 minutes e. Have the client empty her bladder

Answer A, B & E - Before any medication, whether analgesia, anesthesia, labor inducing/ augmenting, antiemetic, is administered during labor, FHR should be assessed to make sure that the fetus is not already compromised. Before regional anesthesia administration, a liter of fluid should be infused to increase the client's vascular fluid volume. This will help to maintain her blood pressure after the epidural insertion. And the client's bladder should be emptied because she will not have the sensation of a full bladder once the epidural is in place.

A woman has just arrived at the labor & delivery suite. In order to report the client's status to her health care provider, which assessments should the nurse perform? (Select all that apply.) a. Fetal heart rate b. Contraction pattern c. Contraction stress test d. Vital signs e. Biophysical profile

Answer A, B, D - A contraction stress test &/or a biophysical profile would only be done if ordered by the health care provider. A, B & D would be completed prior to contacting the provider to provide the provider with a picture of the health status of the client & her fetus.

A nurse is caring for a laboring client who is in transition. Which signs/symptoms would indicate that the client is progressing into the second stage of labor? (Select all that apply.) a. Bulging perineum b. Increased bloody show c. Spontaneous rupture of membranes d. Uncontrollable urge to push e. Inability to breathe through contractions

Answer A, B, D - The three (3) phases of the first stage of labor - latent, active, & transition are related to changes in cervical dilation & maternal behaviors. The three (3) stages of labor are defined by specific labor progressions - cervical change to full dilation (stage 1); full dilation to birth of the baby (stage 2); birth of the baby to birth of the placenta (stage 3).

The nurse is assessing a client who states, "I think I'm in labor." Which finding would positively confirm the client's belief? a. She is contracting every 5 min x 60 sec b. Her cervix has dilated from 2 to 4 cm. c. Her membranes have ruptured. d. The fetal head is engaged.

Answer B - Although laboring women experience contractions, contractions alone are not an indicator of true labor. Only when the cervix begins to dilate is the client in true labor. False labor contractions are usually irregular & mild, but, in some situations, they can appear to be regular & can be quite uncomfortable.

The nurse is assessing the internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which heart rate pattern would the nurse interpret as normal? a. Baseline of 140, moderate variability with V-shaped decelerations to 120 unrelated to contractions. b. Baseline of 140, moderate variability with decelerations to 100 that mirror each of the contractions. c. Flat baseline of 140 with decelerations to 120 that return to baseline after the end of the contraction. d. Flat baseline of 140 with no obvious decelerations or accelerations.

Answer B - Decelerations that mirror contractions are early decelerations. These are related to head compression and are expected during transition & second stage labor.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which finding would the nurses expect to see? a. Decreased pulse rate b. Hypertension c. Hyperthermia d. Decreased respiratory rate

Answer B - During contractions, the blood from the placenta is forced into the peripheral vascular system & there is an increase in cardiac output. As a result, the client's blood pressure rises: an average of 35 mmHg systolic & 25 mmHg diastolic. The blood pressure should never be assessed during a contraction because the reading will be a marked distortion of the client's true blood pressure.

The nurse is performing fetal scalp stimulation. Which fetal response would the nurse expect to see? a. Spontaneous fetal movement b. Fetal heart acceleration c. Increase in fetal heart variability d. Resolution of late decelerations

Answer B - The fetal scalp stimulation test is performed by the health care provider or nurse when FHT are equivocal. For example, if the variability is questionable, the practitioner may perform the stimulation test. If FHT accelerate in response to the test, the nurse interprets the response as a positive sign.

A client had a baby by normal spontaneous vaginal delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina & the umbilical cord lengthened. What should the nurse conclude? a. The client has an internal laceration. b. The client is about to deliver the placenta. c. The client has an atonic uterus. d. The client is experiencing a postpartum hemorrhage

Answer B - The following are normal signs of placental separation: the uterus rises in the abdomen & becomes globular; there is a gush of blood expelled from the vagina; & the umbilical cord lengthens. The placenta should be delivered between 5-30 minutes after delivery of the baby.

A woman, G1P0, 40 weeks' gestation entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2cm dilated, 30% effaced, contracting every 12 minutes x 30 seconds. FHR is in the 140s with moderate variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the health care provider? a. The woman is high risk and should be placed on tocolytics. b. The woman is in early labor and could be sent home. c. The woman is high risk and could be induced. d. The woman is in active labor and should be admitted to the unit.

Answer B - The key facts in this scenario about a primigravida are the cervical dilation, the contraction pattern & the FHR. The woman is in the latent phase because she is only 2cm dilated, 30% effaced, & is contracting infrequently at every 12 minutes with short duration. Plus, the FHR is excellent. She could be sent home as she awaits progression of labor.

The childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which technique did the nurse teach the women to do? a. Alternately pant & blow b. Take rhythmic, shallow breaths c. Push down with an open glottis d. Do slow chest breathing

Answer C - During the second stage of labor the woman will change from using breathing techniques during contractions to pushing during contractions in order to birth the fetus. Open glottis pushing is recommended since pushing against a closed glottis can decrease the mother's oxygen saturation.

A client is in active labor & is being monitored electronically. She has just received Stadol 2 mg IV for pain. Which fetal heart response would the nurse expect to see on the internal monitor tracing? a. Variable decelerations b. Late decelerations c. Decreased variability d. Transient accelerations

Answer C - The analgesics used in labor are opiates. The CNS-depressant effect of opiates is therapeutic for the client who is in pain, but the fetus is also affected by the medication, often exhibiting decreased variability.

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which cardinal move of labor? a. Flexion b. Internal rotation c. Extension d. External rotation

Answer C - The baby must move through the cardinal movements because the fetal head is widest anterior-posterior but the fetal shoulders are widest laterally. On the other hand, the maternal pelvis is widest laterally in the inlet but anterior-posterior at the outlet.

The childbirth education nurse is evaluating the learning of four (4) women, 38-40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the client who makes which statement needs additional teaching? a. The client who says, "If I feel a pain in my back & lower abdomen every 5 minutes." b. The client who says, "When I feel a gush of clear fluid from my vagina." c. The client who says, "When I go to the bathroom & see the mucus plug on the toilet tissue." d. The client who says, "If I ever notice greenish discharge from my vagina."

Answer C - The mucus plug protects the uterine cavity from bacterial invasion. It is expelled shortly before or during the early phase of labor. But, since the client is experiencing no other signs of labor, there is no need for the client to go to the hospital for assessment at this time.

A woman who states that she "thinks "she is in labor enters the labor suite. Which assessment will provide the nurse with the most valuable information regarding the client's labor status? a. Leopold's maneuvers b. Fundal contractility c. Fetal heart assessment d. Vaginal examination

Answer D - All of the assessments listed are performed. However, the only assessment that will determine whether or not the client is in true labor is a vaginal exam. Only when there is cervical change - dilation &/or effacement - is it determined that the client is in true labor.

The nurse sees the fetal head through the vaginal introitus when a client pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state: a. "The baby's head is engaged." b. "The baby is floating." c. "The baby is at the ischial spines." d. "The baby is almost crowning."

Answer D - The baby is crowning when the client's perineal tissues are stretched around the fetal head at the same location where a crown would sit. The station at this time is +4/+5

A client tells the nurse that the first day of her last menstrual period was July 22. What is the estimated date of birth (EDB)? May 7 April 29 April 22 March 6

April 29

With regard to spinal and epidural (block) anesthesia, nurses should know that: A) This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births B) The incidence of after-birth headache is higher with spinal blocks than epidurals. C) Epidural blocks allow the woman to move freely D) Spinal and epidural blocks are never used together.

B) The incidence of after-birth headache is higher with spinal blocks than epidurals.

The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation? Choose all that apply. A) Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency B) Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency C) Uterine resting tone >20 mm Hg D) Uterine resting tone <20 mm Hg E) Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) pattern

B) Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency C) Uterine resting tone >20 mm Hg E) Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) pattern

Vaginal examinations should be performed by the nurse under all of these circumstances EXCEPT: A) An admission to the hospital at the start of labor. B) When accelerations of the fetal heart rate (FHR) are noted. C) On maternal perception of perineal pressure or the urge to bear down. D) When membranes rupture.

B) When accelerations of the fetal heart rate (FHR) are noted.

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's immediate action would be to: A. Change the woman's position. B. Stop the Pitocin. C. Elevate the woman's legs. D. Administer oxygen via a tight mask at 8 to 10 L/min.

B. Stop the Pitocin. RATIONAL: Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present.

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted:

Between 16 and 20 weeks' gestation

With regard to the process of augmentation of labor, the nurse should be aware that it: A) Augmentation is the use of medications to start labor that has not begun yet. B) Relies on more invasive methods when oxytocin and amniotomy have failed. C) Is part of the active management of labor that is instituted when the labor process is unsatisfactory. D) Is a modern management term to cover up the negative connotations of forceps-assisted birth

C) Is part of the active management of labor that is instituted when the labor process is unsatisfactory.

Nurses should be aware that all reputable childbirth methods attempt to meet all these goals except: a) Increase the womans sense of control b) Prepare a support person to help in labor c) Guarantee a pain free childbirth d) Learn distraction techniques

C) guarantee a pain free childbirth

The nurse recognizes that a woman is in true labor when she states: a) I passed some thick, pink mucus when I urinated this morning b) My bag of waters just broke c) The contractions in my uterus are getting stronger and closer together d) My baby dropped and I have to urinate more frequently now

C) the contractions in my uterus are getting stronger and closer together

Which of the following is correct about care for a pregnant woman who has experienced blunt trauma in a car accident? (See Labor Complications Part 4 power point) A) Rhogam is not necessary for rH negative pregnant women after a blunt force trauma. B) If the woman does not have more than 6 ctx an hour she may go home after 4 hours. C) The two most common risks are preterm labor and fetal death. D) In the ER she is evaluated and treated to hemodynamically stabilize her, then she is evaluated with an electronic fetal monitor for a minimum of 4 hours.

D) In the ER she is evaluated and treated to hemodynamically stabilize her, then she is evaluated with an electronic fetal monitor for a minimum of 4 hours.

When assessing the fetus using Leopold maneuvers, the nurse feels a round, hard, movable fetal part just above the symphysis and a long, smooth surface in the mother's left side close to midline. In the fundus, there is a prominence- when pushed the whole body seems to follow. What is the likely position of the fetus? A) RSA B) ROA C) LSP D) LOA

D) LOA p. 422

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following?

Drop in blood pressure.

When would the nurse expect to see the monitor tracing shown below?

During second stage of labor.

While performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position? LOP RSA ROA LOA

ROA

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do?

Take a slow cleansing breath before bearing down.

A pregnant woman comes to the clinic for her first prenatal visit and the nurse is taking her health history. The nurse would be most concerned if the woman gave a history of use of which medication? Synthroid, a thyroid supplement Amoxicillin, an antibiotic Valproic acid, an anti seizure medication Acetaminophen, an over-the-counter pain reliever

Valproic acid, an antiseizure medicatiom

In order to provide an environment that is conducive to bonding for a couple that has just delivered a baby, it is most important to have: a) A quiet room and time to be together b) A home like environment with all of the medical equipment hidden from view c) Adequate time following the birth for the mother to rest before having to care for the baby. d) Time for the parents to be alone together before interacting with the baby

a) A quiet room and time to be together

A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense: a) around the pelvic girdle b) Around the pelvic girdle and in the upper arms c) Around the pelvic girdle and at the perineum d) At the perineum

a) around the pelvic girdle

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: a) counter pressure against the sacrum b) pant-blow (breaths and puffs) breathing techniques c) effleurage d) biofeedback

a) counter pressure against the sacrum

Several assessments can be made while performing a sterile vaginal examination (SVE) during labor, which of the following is least likely to be determined: a) Fetal presentation b) Fetal lie c) Cervical dilation d) Station

a) fetal presentation

With regard to a womans intake and output during labor, nurses should be aware that: a) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia b) IV fluids usually are necessary to ensure that the laboring woman stays hydrated c) Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery d) When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly

a) the tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia

A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she: a) will nott feel the episiotomy b) may lose bladder sensation c) may lose the ability to push d) will no longer feel contractions

a) will not feel the episiotomy

Following influence cervical dilation? choose all that apply: a)strong uterine contractions b) the force of the presenting fetal part against the cervix c) the size of the female d) the pressure applied by the amniotic sac e) scarring of the cervix

a, b, d, e

a nurse is describing the structure and function of the reproductive system to an adolescent health class. how would the nurse describe the secretion of the seminal vesicles? a. mucus-like b. semen c. acidic d. alkaline

alkaline

Chromosomal abnormalities are detected via

amniocentesis

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is:

an application of nitrous oxide

Concerning the third stage of labor, nurses should be aware that: a) the placenta eventually detaches itself from a flaccid uterus b) an expectant or active approach to managing this stage of labor reduces the risk of complications c) it is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface d) the major risk for women during the third stage is a rapid heart rate

an expectant or active approach to managing this stage of labor reduces the risk of complicaitons

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

ans: 1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 4. The fetal heart pattern should be assessed every 1 hour during the latent phase of a low-risk labor. It is not standard protocol to assess every 10 minutes. 5. The nurse should assess the fetal heart before the woman ambulates.

when teaching a group of postmenopausal women about hot flashes & night sweats, the nurse would address which PRIMARY cause? a. change in vaginal pH b. estrogen deficiency c. poor dietary intake d. active lifestyle

b

which measure would the nurse include in the teaching plan for a woman to reduce the risk of osteoporosis after menopause? a. restricting fluid to 1,000 mL daily b. taking vitamin supplements c. eating high-fiber, high-calorie food d. participating in regular daily exercise

b

a 24- yr client who is planning on becoming pregnant comes to the clinic for an evaluation. when assessing the client, which finding would alert the nurse to implement measurements to reduce the clients risk for problems during pregnancy? select all that apply. a. BMI of 22 b. drinks wine 3-4 times/week c. use ibuprofen daily d. follows a vegetarian diet quit smoking 4 years ago

b c

Conscious relaxation is associate with which method of childbirth preparation? a) Grandly dick-read method b) Lamaze method c) Bradley method d) Psychopropylactic method

b) Lamaze

True labor can be differentiated from false labor in that in true labor, contractions will: a) occur immediately after the membranes rupture b) bring about progressive cervical dilation c) be less uncomfortable if client is in side-lying position d) stop when the client is encouraged to walk around

b) bring about progressive cervical dilation

The fundus of your patient is firm, midline, and at the level of the umbilicus. Lochia is saturating more than one peripad per hour. Nursing intervention is based on the knowledge that: a) If the fundus is firm there is no cause to suspect hemorrhage at all b) Excessive bleeding may be caused by lacerations of the birth canal. c) Clots should be expressed from the uterus d) Oxytocin should be added to the IV fluid

b) excessive bleeding may be caused by lacerations of the birth canal

Through vaginal examination, the nurse determines that a woman is 4 cm dilated and the external fetal monitor shows uterine contractions every 3 ½ to 4 minutes. The nurse reports this as: a) First stage, latent phase b) First stage, active phase c) First stage, transition phase d) Second stage, latent phase

b) first stage, active phase

The nurse expects to administer an oxytocic to a woman after expulsion of her placenta to: a) Relieve pain b) Stimulate uterine contraction c) Prevent infection d) Facilitate rest and relaxation e) Administering eye drops and vitamin K

b) stimulate uterine contractions

During the period of induction of labor, a client should be observed carefully for signs of: a) Severe pain b) Uterine tetany c) Hypoglycemia d) Umbilical cord prolapse

b) uterine tetany

Four minutes after the birth of the patient's baby, there is a sudden gush of blood from her vagina and about 8 inches of umbilical cord slides out of her vagina. What should the nurse do? a) Place the bed in Trendelenberg position (head down) b) watch for the emergence of the placenta c) Give IV oxytocin to stop the bleeding d) Roll her onto her side

b) watch for the emergence of the placenta

A nurse is reading a journal article about the use of real-time ultrasonography, which allows the health care provider to obtain information about the fetus. The nurse would expect the article to describe which type of information?

biophysical profile

It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh is isoimmunization, the nurse would expect administer Rho(D) immune globulin at which time? A. 32 weeks' gestation and immediately before discharge b. in the first trimester and within 2 hours of delivery c. at 28 weeks' gestation and again within 72 hours after delivery d. 24 hours before delivery and 24 hours after delivery

c

the nurse is reviewing the laboratory test results of a client with dysfunctional uterine bleeding (DUB). which finding would be of cancer? a negative pregnancy test b. serum cholesterol of 140 mg/dL c. hemoglobin level of 10.0 g/dL d. prothrombin time of 60 seconds

c

which action would the nurse emphasize when teaching postmenopausal women about ways to reduce the risk of osteoporosis? a. taking vitamin A b. swimming daily c. taking Ca supplements d. using hormone replacement

c

The nurse recognizes that a woman is in true labor when she states: a) "I passed some thick, pink mucus when I urinated this morning" b) "My bag of waters just broke" c) "The contractions in my uterus are getting stronger and closer together" d) "My baby dropped and I have to urinate more frequently now"

c) "The contractions in my uterus are getting stronger and closer together"

During the active phase of labor, your patient receives Demoral 25 mg IV; following the administration of Demerol, the nurse should: a) Decrease sensory stimulation in the environment to promote action of the drug b) Assess fetal status c) Assess maternal blood pressure d) Leave the patient alone so that she can rest quietly

c) assess maternal blood pressure

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart rate (FHR) is: a) usually directly over the fetal abdomen b) in a vertex position, heard above the mothers umbilicus c) heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally d) in a breech position, heard below the mothers umbilicus

c) head lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally

When palpating the patient's abdomen, the nurse has difficulty locating the fundus because it is "boggy" or uncontracted. The first nursing action should be to: a) Notify the physician b) Start oxytocin c) Massage the fundus d) Catheterize the client

c) massage the fundus

A laboring woman received merperidine (Demerol) IV 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a) Fentanyl (sublimaze) b) Promethazine (phenergan) c) Naloxone (narcan) d) Nalbuphine (nubain)

c) narcan

A 25 year old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9lb, 7 oz boy after augmentation of labor with oxytocin. She puts on her call light and asks for her nurse right away, stating "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is: a) Retained placental fragments b) Unrepaired vaginal lacerations c) Uterine atony d) Puerperal infection

c) uterine atony

the nurse is assessing a 12 yr old girl who has had her first menses. when reviewing the client's history, which event would the nurse expect to have most likely occurred last? a.evidence of pubic hair b. growth spurt c. onset of menses d. breast bud development

c. onset of menses

The nurse observes the client's amniotic fluid and decides that it appears normal because it is: a) clear and dark amber in color b) milky, greenish yellow, containing shreds of mucus c) clear, almost colorless, and containing little white specks d) cloudy, greenish yellow, and containing little white specks

clear, almost colorless, and containing little white specks

a client comes to the prenatal clinic for her first visit. when determining the client's estimated due date, the nurse understands which method is the most accurate? a. gestational wheel b. birth calculator c. Nagele's rule d. ultrasound

d

a nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. the nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum? a. HPV b. syphillis c. chlamydia d. gonorrhea

d

a nurse is counseling a pregnant woman with rheumatoid arthritis about medications that can be used during pregnancy, Which drug would the nurse emphasize as being CONTRAINDICATED at this time? a. hydroxychloroquine b. glucocorticoid c. NSAID d. methotrexate

d

A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively, she states that she did not attend childbirth classes. The most important nursing action is to: a) Notify the woman's health care provider b) Administer the prescribed narcotic analgesic c) Assure her that her labor will be over soon d) Assist her with simple breathing and relaxation instructions

d) assist her with simple breathing and relaxation instructions

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? a) The umbilical cord shortens in length and changes in color b) A soft and boggy uterus c) Maternal complaints of severe uterine cramping d) Changes in the shape of the uterus

d) changes in the shape of the uterus

All of the following are characteristics of true labor except? a) Fetus presenting part is engaged b) Cervical effacement c) Contractions that increase in intensity d) Irregular contractions

d) irregular contractions

A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: a) transfer her immediately by stretcher to the bathing unit b) tell her to breathe through her mouth and not to bear down c) instruct the client to pant during contractions and to breath through her mouth (i think) d) support the perineum with the hand to prevent tearing and tell the client to pant

d) support the perineum with the hand to prevent tearing and tell the client to pant

Your client is in early labor, and you are discussing the pain relief options she is considering. She states that she wants an epidural "no matter what!" Your best response is: a) Ill make sure you get your epidural b) You may only have an epidural if your doctor allows it c) You may only have an epidural if you are going to deliever vaginally d) The type of analgesia or anesthesia use is determined in part by the stage of your labor and method of birth

d) the type of analgesia or anesthesia use is determined in part by the stage of your labor and method of birth

Urinary frequency in the third trimester, nausea and vomiting during the first trimester, and backache during the second trimester are common ?

discomforts of pregnancy.

Measures to help alleviate nausea and vomiting of pregnancy include

eating small, frequent meals that are bland and low in fat, eating dry crackers, Cheerios, or cheese before getting out of bed, avoiding any strong food odors, limiting the intake of fluids and soups during meals, and eating a high-protein snack before going to bed

The valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and tightening the abdominal muscles. During the second stage of labor, when the woman is ready to push, this is considered the optimal method to enhance movement of the fetus down the birth canal. a) True b) False

false

The health care practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? Calculate to the nearest hundredth.

0.25 ML

After teaching the pregnant woman about ways to minimize flatulence and bloating during pregnancy, the nurse understands that which client statement indicates the need for additional teaching?

"I'll switch to chewing gum instead of using mints."

A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect both diet and insulin needs. How should the nurse respond? "Insulin needs will decrease; the excess glucose will be used for fetal growth." "Diet and insulin needs won't change, and maternal and fetal needs will be met." "Protein needs will increase, and adjustments to insulin dosage will be necessary." "Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."

"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

After an incomplete abortion, a client tells the nurse that although her primary healthcare provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse? "I don't think you should focus on this anymore." "It's when the fetus dies but is retained in the uterus for at least 2 months." "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." "I think it's best for you to ask your primary healthcare provider for the answer to that question."

"It's when the fetus is expelled but other parts of the pregnancy remain in the uterus."

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital?

"The contractions are about a minute long and I am unable to talk through them

Ischial spines are at which station. -2 0 -1 -4

0

pelvic inlet should be ?

12.5 or greater

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 of the following heart rates is noted?

150 beats per minute

check up every week from

37 weeks to birth

It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies:

"A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

What is the best advice a nurse can provide to a pregnant woman in her first trimester? "Cut down on drugs, alcohol, and cigarettes." "Avoid drugs and don't smoke or drink alcohol." "Avoid smoking, limit alcohol consumption, and don't take aspirin." "Take only prescription drugs, especially in the second and third trimesters."

"Avoid drugs and don't smoke or drink alcohol."

What position would be least effective when gravity is desired to assist in fetal descent? A) Lithotomy B) Walking C) Kneeling D) Sitting

A) Lithotomy

The triple marker screens for

AFP, hCG, and unconjugated estriol

Which of the following pictures depicts a fetus in the LSA position

AGAINST LEFT SIDE FACING INWARDS OF TUMMY

A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.

ANS: 1 1. A common side effect of Cytotec is diarrhea and labor contractions are often first felt in the back. 2. Hypothermia and rectal pain are not associated with Cytotec administration. 3. Urinary retention and rash are not associated with Cytotec administration. 4. Tinnitus and respiratory distress are not associated with Cytotec administration. TEST-TAKING TIP: Cytotec (misoprostol) is a synthetic prostaglandin medication used to ripen the cervix for induction. Gastrointestinal side effects are commonly seen when prostaglandin is used, because the gastrointestinal system is adjacent to the vagina where the medication is inserted. In addition, the nurse must be watchful for signs of labor.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

ANS: 1 1. The first action the nurse should take is to place the woman in the knee-chest position. 2. The nurse should assess the fetal heart rate, but this is not the first action. 3. Oxygen should be administered, but this is not the first action. 4. The physician should be advised, but this is not the first action.

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1,000 mL of Ringer's lactate. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.

ANS: 1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should receive an order to infuse Ringer's lactate before the woman is given regional anesthesia. 3. It is not necessary to place the woman in the Trendelenburg position. 4. The blood pressure will need to be monitored every 5 minutes for 15 minutes after administration of the anesthesia, but not before. 5. The nurse should ask the woman to empty her bladder.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.

ANS: 3 1. The client is hemodynamically stable. Her blood pressure needs to be assessed about every 1 hour at this time. 2. The client is hemodynamically stable. Her pulse needs to be assessed about every 4 hours at this time. 3. The client's bladder should be palpated. 4. There is nothing in the scenario that implies that the client's lung fields need to be assessed.

Which of the following situations in a fully dilated client is incompatible with a forceps delivery? Select all that apply. 1. Maternal history of asthma. 2. Right occiput posterior position at +4 station. 3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute at -1 station. 5. Maternal history of cerebral palsy.

ANS: 3 and 4 are correct. 1. Asthmatic clients, although needing careful monitoring, are able to deliver vaginally. 2. It would be appropriate to deliver a baby whose position and station are ROP and +4 via forceps. 3. A baby in transverse lie is physically incapable of delivering vaginally. 4. It is not appropriate to deliver a baby vaginally who is at -1 station. The baby has yet to engage. This baby would likely be delivered by cesarean section for prolonged fetal distress. 5. Clients with cerebral palsy may be delivered with forceps.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0? (Select all that apply.) a. After vaginal exams b. Before administration of analgesics c. Periodically at the end of a contraction d. Every ten (10) minutes e. Before ambulating

Answer A, B, C, & E - Except for invasive procedures, assessment of the FHR pattern is the only way to evaluate the well-being of a fetus during labor. The FHR pattern should, therefore, be assessed whenever there is a potential for injury to the fetus or to the umbilical cord. At each of the times noted in the scenario either the cord could be compressed or the fetus could be compromised.

Which response is the primary rationale for providing general information as well as breathing & relaxation exercises in childbirth education classes? a. Mothers who are doing breathing exercises during labor will refrain from yelling. b. Breathing & relaxation exercises are less exhausting than crying & moaning. c. Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle. d. Childbirth education classes help to promote positive maternal-newborn bonding.

Answer C - When a frightened woman enters the labor suite, she is likely to be very tense. It is known that pain is often worse when tensed muscles are stressed. Once the woman feels pain, she may become even more frightened & tense. This process becomes a vicious cycle. The information & skills learned at childbirth education classes are designed to break the cycle.

A nurse is teaching a class of pregnant couples the most therapeutic breathing techniques for the latent phase of labor. Which technique did the nurse teach? a. Alternately panting & blowing b. Rapid, deep breathing c. Grunting & pushing with contractions d. Slow paced breathing

Answer D - Because the latent phase is the first phase of the first stage of labor, contractions are usually mild & they rarely last longer than 30 seconds. A slow paced breathing technique, therefore, is effective & does not tire the woman out for the remainder of her labor.

It is 4pm. A client, G1P0, 3cm, asks the nurse when the dinner tray will be served. The nurse replies a. "Laboring clients are never allowed to eat." b. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." c. "The dinner tray should arrive in an hour or two." d. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

Answer D - Peristalsis slows dramatically during labor. Because of this, women rarely become hungry during labor, but they do need fluids & some nourishment. Clear liquids are often allowed. Ultimately, though, it is the health care provider's decision what & how much the client may consume.

A multiparous client who has been in labor for almost 3 hours suddenly announces that the baby is coming. The nurse sees the infant crowning. Which intervention should the nurse do immediately? A. Ask the woman to pant while preparing to place gentle counterpressure on the infant's head as it is delivered B. Quickly obtain sterile gloves & a towel C. Retrieve the precipitous delivery tray from the nursing station D. Telephone the health care provider using the bedside phone

Answer: A.

During augmentation of labor with IV oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic and complains of severe lover abdominal pain with a tearing sensation. Fetal distress is noted on the monitor. The nurse should suspect: A. Precipitous labor B. Amniotic fluid embolus C. Rupture of the uterus D. Uterine prolapse.

Answer: C.

What assessment is least likely to be associated with a breech presentation? A) Fetal heart tones heard at or above the maternal umbilicus B) Meconium-stained amniotic fluid C) Postterm gestation D) Preterm labor and birth

C) Postterm gestation

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time?

Have the woman breathe into a bag.

LIst 4 critical factors in labor (the 5 Ps)

Passenger, Passageway, Powers, positions, psychological response

Alpha-fetoprotein

a substance produced by the fetus. AFP enters the maternal circulation by crossing the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus. The optimal time for AFP screening is 16 to 18 weeks

Fetal presentation refers to which of the following description? a) Fetal body part that enters the maternal pelvis first b) Relationship of the presenting part to the maternal pelvis c) Relationship of the long axis of the fetus to the long axis of the mother d) A classification according to the fetal part

a) fetal body part that enters the maternal pelvis first

A patient has requested a saddle block with delivery. After administration of the anesthesia the most immediate nursing intervention is to monitor: a) Fetal heart rate b) Maternal blood pressure c) Frequency of contractions d) Progress of labor

b) Maternal blood pressure

When the fetal presenting part is at the woman's perineurium and birth Is imminent, the baby is said to be at which station? a) 0 b) +2 c) +5 d) -5

c) +5

A nulliparous woman who has just begun the second stage of her labor most likely: a) experiences a strong urge to bear down b) shows perineal bulging c) feels tired yet relieved that the worst is over d) shows an increase in bright red bloody show

c) feels tired yet relieved that the worst is over

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: a) Hematoma b) Placenta previa c) Uterine atony d) Placental separation

d) placental separation

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

d) transitional phase

Amniocentesis

is used to evaluate for neural tube defects, chromosomal disorders, and inborn errors of metabolism.

Analgesia is not administered prior to the establishment of effective labor primarily because it might:

prolong labor

Percutaneous umbilical blood sampling allows for ?

rapid chromosomal analysis.

A nurse is teaching a client who is 30 weeks pregnant about ways to deal with heartburn. The nurse determines a need for additional teaching based on which client statement?

"I should lie down for 1/2 hour after eating."

check up every 2 weeks from

29-36 weeks

A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse? A) A dipstick value of 3+ for protein in her urine B) Pitting pedal edema at the end of the day C) Blood pressure (BP) increase to 138/86 mm Hg D) Weight gain of 0.5 kg during the past 2 weeks

A) A dipstick value of 3+ for protein in her urine

A client is hospitalized on the antepartum unit with premature rupture of membranes at 37 weeks' gestation. Which routine physician prescription would the nurse question for this client? A. Limited sterile vaginal exams B. Diet as tolerated C. External fetal monitor prn D. Vital signs every shift

Answer: D.

At the first prenatal visit, the client reports her LMP was November 16, 2017. The nurse determines the estimated due date to be

August 23, 2018

During labor, the patient at 4 cm suddenly becomes dyspneic, cyanotic, and hypotensive. The nurse must prepare immediately for: (Select all that apply.) A) Immediate vaginal delivery B) Cesarean delivery C) CPR D) McRobert's maneuver

B) Cesarean delivery C) CPR

Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: A) First stage, latent phase B) First stage, active phase C) First stage, transition phase D) Second stage, latent phase

B) First stage, active phase

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time?

Continue to provide encouragement during each contraction.

During labor a fetus with an average heart rate of 175 beats/min over a 15-minute period would be considered to have: A) A normal baseline heart rate. B) Bradycardia. C) Hypoxia. D) Tachycardia.

D) Tachycardia. p. 429

When would the nurse expect to see the fetal heart changes noted on the monitor tracing shown below?

During fetal movement.

Which test is performed to determine if membranes are ruptured?

Fern test

The fetus is most likely to be damaged by the pregnant women's ingestion of drugs during the

First triemester

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?

It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

A client who is at 13 weeks' gestation arrives at the emergency department. She states that she began to have spotting and a small amount of vaginal bleeding several hours ago. This is her second pregnancy. Which gravidity should the nurse record? Multipara Primipara Multigravida Primigravida

Multigravida

A client at 24 weeks' gestation arrives at the clinic for a routine examination. She tells the nurse, "I feel puffy all over." In light of this statement, what is the nurse's most important assessment? Obtaining her blood pressure Determining how much salt she uses Asking the extent of her daily fluid intake Reviewing her history for total weight gain

Obtaining her blood pressure

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if which is observed?

Petechiae, oozing from injection sites, and hematuria

A woman who is in active labor is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say?

The baby's chin is resting on its chest

Prior to administration of an epidural anesthetic, what explanation should the nurse give to the woman and her partner:

The medication is placed through a tube in your back. It keeps the pain from your uterus from reaching your brain

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time

The relationship between the decelerations and the labor contractions

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner?

The woman is in early labor and could be sent home.

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? Turn her onto her left side Elevate the head of the bed Place her feet on several pillows Give her oxygen via a face mask

Turn her onto her left side

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of:

Two umbilical arteries and one umbilical vein

A pregnant woman is discussing positioning and the use of leg stirrups for delivery with a labor nurse. Which of the following client responses indicates that the client understood the information? Select all that apply.

When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups

a woman pregnant with twins comes to the clinic for an evaluation. the nurse closely assesses the client for which potential problem a. post-term labor b. oligiohydramnios c. chorioaminionitis d. preeclampsia

d

The process of taking-up the cervical canal by the uterine walls and changing into a paper thin circular structure is known as:

effacement

Eating mints can help reduce

flatulence

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see?

pH of 7.30.

famotidine

s a category B drug that has been used frequently during pregnancy and does not appear to cause major birth defects or other fetal problems.

chewing gum increases the amount of air that is

swallowed

A fundus of 12 weeks' gestation is palpated

symphis pubis

The client should remain sitting for 1 to 3 hours after eating and avoid lying down within 3 hours of eating. true or false?

true

The period encompassing the first 1-2 hours after birth often is referred to as the ___ stages of labor

4th

The nurse caring for the woman in labor should understand that maternal hypotension can result in: A) Uteroplacental insufficiency. B) Spontaneous rupture of membranes C) Fetal dysrhythmias. D) Early decelerations.

A) Uteroplacental insufficiency.

A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask

ANS: 1 1. The nurse should assess the fetal heart and the maternal pulse simultaneously. 2. It is not necessary to notify the doctor at this time. 3. It is not necessary to stop the medication at this time. 4. It is not necessary to administer oxygen to the mother at this time.

While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats per minute that lasts 15 seconds. How should the nurse document this event? An acceleration An early increase A sonographic motion A tachycardic heart rate

An acceleration

On exam, it is noted that a full-term primipara in active labor is right occipitoanterior position (ROA), 7 cm dilated, & +2 station. What should the nurse report to the health care provider? a. Descent is progressing well. b. Fetal head is not yet engaged. c. Vaginal delivery is imminent. d. External rotation is complete.

Answer A - In a 7 cm dilated primipara, with a fetus at +2 station, vaginal delivery is not imminent, but the fetal head is well past engagement & descent is progressing well. External rotation has not yet occurred since the baby's head has not yet been birthed.

A client is in the third stage of labor. Which assessment should the nurse make/observe for? a. Fetal heart assessment after each contraction b. Uterus rising in the abdomen & feeling globular c. Rapid cervical dilation to ten (10) cm d. Maternal complaints of intense rectal pressure

Answer B - It is important to differentiate between the stages of labor. Stage 1, what is usually referred to as "labor", ends with full cervical dilation. At the end of stage 2, the baby is born. At the conclusion on stage 3, the placenta is expelled.

Immediately following administration of an epidural anesthesia, the nurse must monitor the client for: a. Paresthesias in her feet & legs b. Drop in blood pressure c. Increase in central venous pressure d. Fetal heart accelerations

Answer B - Virtually all clients will show signs of hypotension after epidural administration. The change is related to two (2) phenomena: dilation of the vessels of the pelvis & increased compression of the vena cava.

The client is receiving IV magnesium sulfate at 2 gm/hr to stop premature labor. The nurse determines that the most important nursing assessment of this client includes: A. I & O, LOC & BP B. BP, P & uterine activity C. DTRs, hourly urine output & respiratory rate D. I & O, BP & DTRs

Answer: C.

The nurse determines that fetal distress is occurring after noting which sign? A. Moderate amount of bloody show B. Pink-tinged amniotic fluid C. Meconium-stained amniotic fluid D. Acceleration of fetal heart rate w/each contraction

Answer: C.

The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform a vag exam. The most appropriate intervention is to: A. Call the health care provider immediately B. Place a moist, clean towel over the cord to prevent drying C. Immediately turn the client on her side & listen to the fetal heart rate D. Perform a vag exam & apply upward digital pressure to the presenting part while having the mother assume a knee-chest position.

Answer: D

Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: A) Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. B) Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. C) Effleurage is permissible, but counterpressure is almost always counterproductive. D) Electrodes attached to either side of the spine to provide mild-intensity electrical impulses facilitate the release of endorphins.

D) Electrodes attached to either side of the spine to provide mild-intensity electrical impulses facilitate the release of endorphins.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure? Choose all that apply. A) Place the woman in a supine position. B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. D) Continuous Fetal Monitor E) Administer ephedrine per MD order

B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. E) Administer ephedrine per MD order

With regard to a pregnant woman's anxiety and pain experience, nurses should be aware that: A) Even mild anxiety must be treated. B) Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. C) Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. D) Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

B) Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on.

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A. Encourage the woman to breathe more slowly. B. Help the woman breathe into a paper bag. C. Turn the woman on her side. D. Administer a sedative.

B. Help the woman breathe into a paper bag. RATIONAL: The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level.

A woman is evaluated to be using an effective bearing-down effort if she: A. Begins pushing as soon as she is told that her cervix is fully dilated and effaced. B. Takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. C. Uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. D. Continues to push for short periods between uterine contractions throughout the second stage of labor.

B. Takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. RATIONAL: Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal.

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."

D. "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage." RATIONAL: 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.

What is an advantage of external electronic fetal monitoring? A) Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions. B) The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs). C) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring. D) The external EFM can accurately record FHR all the time.

C) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring. p. 426

The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by: A) Altered cerebral blood flow B) Spontaneous rupture of membranes C) Uteroplacental insufficiency D) Umbilical cord compression

C) Uteroplacental insufficiency p. 432; see box 17-4

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time?

Encourage the woman to grunt during contractions.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first?

Encourage the woman to perform the next level breathing.

A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. What is the most therapeutic nursing intervention for this client at her follow-up appointment? Focusing on the client's physical needs Encouraging the client to verbalize her feelings about the loss Reminding the client that she will be able to become pregnant again Encouraging the client to think of herself, her husband, and their future

Encouraging the client to verbalize her feelings about the loss

Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply.

Engage in sexual intercourse. Ingest evening primrose oil. Massage the breast and nipples.

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what? Estimate fetal age Detect hydrocephalus Rule out congenital defects Approximate fetal linear growth

Estimate fetal age

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first?

Evaluate the progress of labor.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? First Second Prodromal Transitional

First

The nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor has this client reached? First Latent Second Transitional

First

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time? Having the client empty her bladder Watching for signs of retained secundines Massaging the uterus vigorously to prevent hemorrhage

Have the client empty her bladder

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belie

Her cervix has dilated from 2 to 4 cm.

While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action at this time? Monitoring the fetal heart rate Covering the cord with a saline dressing Pushing the cord back into the vaginal vault Holding the presenting part away from the cord

Holding the presenting part away from the cord

A client at her first visit to the prenatal clinic states that she has missed three menstrual periods and thinks that she is carrying twins because her abdomen is so large. She now has a brownish vaginal discharge. Her blood pressure is increased, indicating that she may have gestational hypertension. What condition does the nurse suspect the client may have? Renal failure Placenta previa Hydatidiform mole Abruptio placentae

Hydatidiform mole

The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? Cerebral hemorrhage Pulmonary edema Impending seizures Hypovolemic shock

Hypovolemic shock

After teaching a pregnant woman how to count fetal movements, the nurse determines that the teaching was successful when the client makes which statement?

I'll sit comfortably in a recliner or lie on my side when I do the counts."

While caring for a client during labor, what does the nurse remember about the second stage of labor? It ends at the time of birth. It ends as the placenta is expelled. It begins with the transition phase of labor. It begins with the onset of strong contractions.

It ends at the time of birth.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?

July 27, 2017

Which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes

Knowledge learned at childbirth education classes helps to break the feartension- pain cycle

A nurse performs Leopold maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is what? LOA ROA LMP RMP

LOA

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment?

LSP −1 station.

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply.

Lengthening of the umbilical cord Uterus rising in the abdomen and feeling globular

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, and fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect? Preterm labor Uterine inertia Placenta previa Abruptio placentae

Placenta previa

A client in labor is admitted with a suspected breech presentation. Which occurrence should the nurse be prepared for? Uterine inertia Prolapsed cord Imminent birth Precipitate labor

Prolapsed cord

A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. Which physiologic finding does the nurse suspect is the cause of this abrupt change? Fetal acidosis Prolapsed cord Head compression Uteroplacental insufficiency

Prolapsed cord

The nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate? Hypotension Decreased fetal heart rate Unusual uterine enlargement Painless, heavy vaginal bleeding

Unusual uterine enlargement

a pregnant woman in the 36 week of gestation reports that her feet are quite swollen at the end of the day. after careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. which intervention is appropriate for the nurse to suggest? a. try elevating your legs when you sit b. wear spandex-type full-length pants c. limits your intake of fluids d. eliminate salt from your diet

a

the nurse is reviewing the process of oocyte maturation and ovulation with a client. what occurs during the follicular phase of the ovarian cycle that the nurse should include in the teaching session on ovulation with the client? a. under the influence of follicle-stimulating hormone, several follicles begin to ripen, and the ovum with each begins to mature b. about day 14, a surge of hormones cause the ovum to birthing through the ovary c. preparation of the uterus for implantation of an ovum d. the empty ruptured Graafian follicle becomes the corpus lute and it begins to secrete progesterone and estrogen

a

when preparing a women for an amniocentesis, the nurse would instruct her to perform which action? a. lie on the left side b. empty bladder c. shower with an antiseptic scrub d. swallow the preprocedure sedative

b

A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? a)hypotonic contractions b) forceps delivery c) shultz delivery d) weak bearing down efforts

b) forceps delivery

A woman who has a history of sexual abuse may have a number of traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care? a) Tell the client to relax and that it wont hurt much b) Limit the number of procedures that invade her body c) Reassure the client that as the nurse you know what is best d) Allow unlimited care providers to be with the client

b) limit the number of procedures that invade her body

With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that: a) the seven critical movements must progress in a more or less orderly sequences b) Asynclitism sometimes is achieved by means of Leppold maneuver c) The effects of the forces determining descent are modified by the shape of the women's pelvis and the size of the fetal head d) At birth that baby is said to acheive "restitution"; that is, a return to the C-shape of the womb

c) The effects of the forces determining descent are modified by the shape of the women's pelvis and the size of the fetal head

During anesthetic management of the morbidly obese woman in labor, the nurse must remain alert for complications specific to this type of client. Which is not a concern for the L&D nurse? a) Failed epidural placement b) Accidental dural puncture c) Inadequate pain relief d) Difficult intubation

c) inadequate pain relief

For which of the following women would administration of IV analgesia seem most appropriate? a) primigravida at 3cm dilation, complete effacement, contractions moderate intensity, duration 40s, occuring every 6-7 minutes b) multigravida at 9cm, contractions of strong intensity, duration 90s, occurring every 3 minutes c) multigravida at 6cm, contractions strong intensity, duration 80s, occurring every 3-4 minutes d) primigravida completely dilated at station +3 with strong contractions occurring every 3 minutes

c) multigravida at 6cm, contractions strong intensity, duration 80s, occurring every 3-4 minutes

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond? a) let the client get up to use the potty b) allow the pt to use a bedpan c) perform a pelvic exam d) check the fetal heart rate

c) perform a pelvic exam

According to professional standards (AWHONN, 2007), the nonanesthestis registered nurse caring for a woman with an epidural is permitted to perform all actions except: a) monitor status of the woman and fetus b) initiate epidural anesthesia c) replace empty infusion bags with the same medication and concentrate d) stop the infusion and initiate emergency measures

c) replace empty infusion bags with the same medications and concetrate

The nurse knows that the second stage of labor, the descent phase, has begun when: a) The amniotic membranes rupture b) The cervix cannot be felt during a vaginal examination c) The woman experiences a strong urge to bear down d) The presenting part is below the ischial spines

c) the woman experiences a strong urge to bear down

To promote comfort, a 24 y/o gravida 2, para 1 client is encouraged to assume certain positions while in labor and to avoid others. Which of the following should not be used during labor? a) Lateral positions b) Squatting positions c) Standing position d) Semi-fowlers position e) Supine position

e) supine position

clt. adm. 39 weeks gestation for induction of labor. Doc uses prostaglandin gel the nurse should adm. stadol prior to the prostaglandin gel tell the clt. that the labor will be more painful elevate the clt. hips for 30 mins after gel is inserted insert a foley cath prior to insertion of the gel

elevate the clt. hips for 30 mins after gel is inserted

During a follow-up visit to the prenatal clinic, a pregnant client asks the nurse about using a hot tub to help with her backache. The nurse recommends against the use based on the understanding that what can occur?

fetal tachycardia

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. Prior to initiation of the epidural the woman should be informed regarding the disadvantages of an epidural block. They include all except: (ability to move freely is limited, orthostatic hypotn and dizziness, higher rate of fever, gastric emptying is not delayed)

gastric emptying is not delayed

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider. Which signs and symptoms would the nurse include? Select all that apply.

headache with visual changes in the third trimester sudden leakage of fluid during the second trimester lower abdominal pain with shoulder pain in the first trimester

Epidural Block has just been given to your patient. The nurse notes that her sys blood pressure has dropped from 120 mm Hg to 96 mm Hg. The nurse's first action would be to:

increase the rate of IV fluids, and start o2 by mask

Chorionic villus sampling (CVS)

procedure for obtaining a sample of the chorionic villi for prenatal evaluation of chromosomal disorders, enzyme deficiencies, fetal gender determination, and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay-Sachs disease

The most common method of kick counting is

"Count to 10," whereby a woman focuses her attention on her fetus's movement and records how long it takes to document 10 movements.

A couple comes to the family planning clinic and asks about sterilization procedures. Which questions by the nurse would determine whether this method of family planning would be appropriate?

"Do you plan to have any other children?"

The diagonal conjugate of a pregnant woman's pelvis is measured. Which measurement would the nurse interpret as presenting a potential problem?

12.0 cm

The physician writes the following order for a newly admitted client in labor: Begin a 1000 mL IV of D5 1/2 NS at 150 mL/hr. The IV tubing states that the drop factor is 10 gtt/mL. Please calculate the drip rate to the nearest whole. _______ gtt/min

25 GTT/MIN

A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every:

4 weeks

A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to: A. Assess the fetal heart rate (FHR) pattern. B. Perform a vaginal examination. C. Inspect the characteristics of the fluid. D. Assess maternal temperature.

A. Assess the fetal heart rate (FHR) pattern. RATIONAL: The first nursing action after the membranes are ruptured is to check the FHR. Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy).

When performing vaginal examinations on laboring women, the nurse should be guided by what principle? A. Cleanse the vulva and perineum before and after the examination as needed B. Wear a clean glove lubricated with tap water to reduce discomfort C. Perform the examination every hour during the active phase of the first stage of labor D. Perform immediately if active bleeding is present

A. Cleanse the vulva and perineum before and after the examination as needed RATIONAL: Cleansing will reduce the possibility of secretions and microorganisms ascending into the vagina to the cervix. Maternal comfort will also be enhanced. Examinations are never done by the nurse if vaginal bleeding is present since the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: A. Progressive uterine contractions. B. Lightening. C. Rupture of membranes. D. Passage of the mucous plug (operculum).

A. Progressive uterine contractions.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A. The fetal presenting part is 1 cm above the ischial spines. B. Effacement is 4 cm from completion. C. Dilation is 50% completed. D. The fetus has achieved passage through the ischial spines.

A. The fetal presenting part is 1 cm above the ischial spines.

The nurse is assessing the fetal station during a vaginal exam. Which structures should the nurse palpate? a. Sacral promontory b. Ischial spines c. Cervix d. Symphysis pubis

Answer B - Station is determined by creating an imaginary line between the ischial spines. The descent of the presenting part of the fetus is then compared with the level of that "line".

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should come to the hospital to be evaluated. Which statement by the woman indicates that she is probably in labor & should proceed to the hospital? a. "The contractions are 5 to 20 minutes apart." b. "I saw a pink discharge on the toilet tissue when I went to the bathroom." c. "I have had cramping for the past 3 or 4 hours." d. "The contractions are about a minute long & I am unable to talk through them."

Answer D - Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen.

The nurse monitors a client during a vaginal delivery of a breech infant for which of the following as the greatest risk? A. Umbilical cord prolapse B. Intracranial hemorrhage C. Meconium aspiration D. Fracture of the clavicle.

Answer: A.

Concerning the third stage of labor, nurses should be aware that: A) The placenta eventually detaches itself from a flaccid uterus B) An active approach to managing this stage of labor reduces the risk of excessive bleeding C) It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. D) The major risk for women during the third stage is a rapid heart rate.

B) An active approach to managing this stage of labor reduces the risk of excessive bleeding

Perinatal nurses are legally responsible for: A) Applying the external fetal monitor and notifying the care provider. B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. C) Greeting the client on arrival, assessing her, and starting an intravenous line. D) Making sure that the woman is comfortable.

B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. p. 434

While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate in a slow curve at the onset of several contractions and returns to baseline before each contraction ends. The nurse should: A) Insert an internal monitor B) Document the finding in the client's record. C) Discontinue the oxytocin infusion D) Change the woman's position

B) Document the finding in the client's record. p. 430

With regard to systemic analgesics administered during labor, nurses should be aware that: A) Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B) Effects on the fetus and newborn can include decreased alertness and delayed sucking. C) Intramuscular administration (IM) is preferred over intravenous (IV) administration. D) IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

B) Effects on the fetus and newborn can include decreased alertness and delayed sucking.

What is an expected characteristic of amniotic fluid? A) Deep yellow color B) Pale, straw color with small white particles C) Acidic result on a Nitrazine test D) Absence of ferning

B) Pale, straw color with small white particles

Which characteristic is associated with false labor contractions? A. Painless B. Decrease in intensity with ambulation C. Regular pattern of frequency established D. Progressive in terms of intensity and duration

B. Decrease in intensity with ambulation RATIONAL: Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation.

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: A. Maternal hyperthyroidism. B. Initiation of epidural anesthesia that resulted in maternal hypotension. C. Maternal infection accompanied by fever. D. Alteration in maternal position from semirecumbent to lateral.

B. Initiation of epidural anesthesia that resulted in maternal hypotension. RATIONAL: Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR pattern.

Your client is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, "Why is it taking so long?" The most appropriate response by the nurse would be: A) "Your baby is just being stubborn." B) "The length of labor varies for different women." C) "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor." D) "I don't know why it is taking so long."

C) "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor."

The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of: A) Uterine contractions occurring every 8 to 10 minutes B) Rupture of the client's amniotic membranes. C) A fetal heart rate (FHR) of 180 with absence of variability. D) The client needing to void.

C) A fetal heart rate (FHR) of 180 with absence of variability.

A number of methods to assist in the assessment of fetal well-being have been developed for use in conjunction with electronic fetal monitoring. These various technologies assist in supporting interventions for a nonreassuring fetal heart rate pattern when necessary. The labor and delivery nurse should be aware that one of these modalities, fetal oxygen saturation monitoring, includes the use of: A) Fetal blood sampling B) Umbilical cord acid-base determination C) Fetal pulse oximetry. D) A fetal acoustic stimulator.

C) Fetal pulse oximetry. p. 436 (book says this has been withdrawn from the market)

A laboring woman received meperidine (Demerol) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? A) Fentanyl (Sublimaze) B) Promethazine (Phenergan) C) Naloxone (Narcan) D) Nalbuphine (Nubain)

C) Naloxone (Narcan)

Magnesium sulfate is given to women with preeclampsia and eclampsia to: A) Improve patellar reflexes and increase respiratory efficiency. B) Shorten the duration of labor. C) Prevent and treat convulsions. D) Prevent a boggy uterus and lessen lochial flow.

C) Prevent and treat convulsions.

Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to prevent cord compression would be to: A. Place woman in a supine position and elevate legs from the hips. B. Insert a Foley catheter to keep the bladder empty. C. Keep the protruding cord moist with warm sterile normal saline compresses. D. Attempt to reinsert the cord.

C. Keep the protruding cord moist with warm sterile normal saline compresses.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A. Encourage her to empty her bladder. B. Decrease her intravenous (IV) rate to a keep vein-open rate. C. Turn the woman to the left lateral position or place a pillow under her hip. D. No action is necessary since a decrease in the woman's blood pressure is expected.

C. Turn the woman to the left lateral position or place a pillow under her hip. RATIONAL: Turing the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction.

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? Prolong the course of labor Cause decreased placental perfusion Lead to transient episodes of hypertension Interfere with free movement of the coccyx

Cause decreased placental perfusion

A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider regarding breech presentations when caring for this client? Severe back discomfort will occur. Length of labor usually is shortened. Cesarean birth probably will be necessary. Meconium in the amniotic fluid is a sign of fetal hypoxia.

Cesarean birth probably will be necessary.

A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for? Cord prolapse Placenta previa Chorioamnionitis Abruptio placentae

Chorioamnionitis The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: A) Notify the woman's physician. B) Tell the woman to "calm down" and slow the pace of her breathing. C) Administer oxygen via a mask or nasal cannula. D) Help her breathe into a paper bag

D) Help her breathe into a paper bag

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: A. Weight gain of 1 to 3 pounds. B. Quickening. C. Fatigue and lethargy. D. Bloody show.

D. Bloody show. RATIONAL: Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens.

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is: A. Severe postpartum headache. B. Limited perception of bladder fullness. C. Increase in respiratory rate. D. Hypotension.

D. Hypotension. RATIONAL: Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? A. FHR does not change as a result of fetal activity. B. Average baseline rate ranges between 100 and 140 beats/min. C. Mild late deceleration patterns occur with some contractions. D. Variability averages between 6 to 10 beats/min.

D. Variability averages between 6 to 10 beats/min. RATIONAL: Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see?

Hypertension.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate?

Ischial spines.

A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravid arum. She is to be maintained at home with rehydration infusion therapy. What is the nursing priority for the home health nurse? Determing fetal-well being Monitoring signs of infection Monitoring the client for signs of electrolyte imbalances Teaching about changes in nutrional needs during pregancy

Monitoring the client for signs of electrolyte imbalances

What is the priority nursing intervention during the admission of a primigravida in labor? Monitoring the fetal heart rate Asking the client when she ate last Obtaining the client's health history Determining whether the membranes have ruptured

Monitoring the fetal heart rate

In addition to breathing with contractions, which of the following actions can help a woman in the first stage of labor to work with her pain?

Performing effleurage.

During the vaginal exam, you determine that the posterior fontanel is toward the mother's back on the right side. What is the fetal position?

Right occiput posterior (ROP)

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode?

Right upper quadrant (RUQ).

Severe preeclampsia. What objective finding indicates an impending seizure? Persistent headache with blurred vision Epigastric pain with nausea and vomiting Spots and flashes of light before the eyes Rolling of the eyes to one side with fixed stare

Rolling of the eyes to one side with fixed stare

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?.

The client complains of a headache and blurred vision.

The client has delivered a healthy infant and is now being taken to the recovery room. Which clinical observation is most critical for the nurse to make at this time?

Vaginal bleeding

Should you notify her health care provider (HCP) at this time? If so, what info will you give and what medical interventions do you anticipate?

Yes. Her HCP needs to be aware of lack of progress, contraction status & fetal position. Augmentation of labor with oxytocin (Pitocin) may be prescribed to correct hypotonic uterine dysfunction. Continuous assessment of contractions, fetal heart rate, maternal response and labor progress is warranted.

Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders IV administration of oxytocin (Pitocin),. Why must the nurse monitor the patient's fluid intakes and output closely during oxytocin administration? a)Oxytocin causes water intoxication b) Oxytocin causes excessive thirst c) Oxytocin is toxic to the kidneys d) Oxytocin has a diuretic effect

a) oxytocin causes water intoxication

Breathing patterns are taught to laboring women. Which breathing pattern would the nurse support for the woman and her coach during the latent phase of the first stage of labor with a couple had attended Lamaze classes? a) Slow-paced breathing b) Deep abdominal breathing c) Modified-paced breathing d) Patterned-paced breathing

a) slow-paced breathing

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: a) not yet engaged b) entering the pelvic inlet c) below the ischial spines d) visible at the vaginal opening

below the ischial spines

s. Rh incompatibility and HIV status are both evaluated by

blood tests

Isotretinoin and warfarin

category X drugs and should never be taken during pregnancy.

A young couple are concerned that their fetus may be born with sickle cell anemia. The nurse explains that the recessive traits of sickle-cell anemia can be determined by using which test?

chorionic villus sampling

A client is in her second trimester, and the health care provider has recommended she undergo an amniocentesis. The nurse explains that the procedure is used to diagnose which conditions? Select all that apply

chromosomal abnormalities inborn errors of metabolism neural tube defects

The nurse expects which maternal cardiovascular finding during labor: Increased cardiac output Decreased pulse rate Decreased WBC count Decreased blood pressure

increased cardiac output

The slight overlapping of cranial bones or shaping of the fetal head during labor is called:

molding

Because the patient has received an oxytocic drug, it will be necessary to include which of these measures in her care?

monitoring her BP

A nurse is conducting a class with group of pregnant women who are all in their first trimester of pregnancy. During the class, the women are discussing the various discomforts that they are experiencing. The nurse would expect to hear complaints about which discomforts? Select all that apply.

nausea urinary frequency breast tenderness

A leopold's maneuver step #3 you palpated a hard round moveable mass at the supra pubic area. The correct interpretation is that the mass palpated is:

the mass is the head

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear

"I can't stand this pain any longer!"

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time?

2 cm.

A nurse is teaching a pregnant woman how to perform fetal kick counts. The nurse determines that the teaching was successful when the client states that she will call her healthcare provider if it takes longer than what time frame to reach 10 kicks?

2 weeks

first week check up schedule is every 4 weeks up to

28 weeks

. A woman should report a count of less than

3

During the third stage, the following physiological changes occur. Please place the changes in chronological order.

31. Hematoma forms behind the placenta. 42. Membranes separate from the uterine wall. 13. The uterus contracts firmly. 24. The uterine surface area dramatically decreases.

At the first prenatal visit of all clients who come to the clinic appropriate blood screenings are obtained. The nurse realizes that a hemoglobin A1c above which level is concerning for diabetes and warrants further testing?

6.5%

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for ____ has increased a) Intrauterine infection b) Hemorrhage c) Precipitous labor d) Supine by potension

A) intrauterine infection

A woman, 32 weeks' gestation, contracting every 3 min s 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.

ANS: 1 1. The urinary output should be carefully monitored. 2. Magnesium sulfate administration does not place clients at high risk for a temperature elevation. 3. Magnesium sulfate administration does not place clients at high risk for cessation of peripheral circulation. 4. Magnesium sulfate administration does not place clients at high risk for retinal edema.

Which choice includes the correct order of the cardinal moves of labor? a. Internal rotation, extension, external rotation b. External rotation, descent, extension c. Extension, flexion, internal rotation d. External rotation, internal rotation, expulsion

Answer A - Descent & flexion must occur first. If the fetus does not descend into the birth canal & the fetus does not flex the head, the fetus will not be able to traverse through the bony pelvis. Second, internal rotation must occur before external rotation. In between internal rotation & external rotation is extension, the delivery of the head. And, finally, expulsion of the body

During a vaginal exam, the nurse palpates fetal buttocks that are facing the left posterior & are 1 cm above the ischial spines. This is consistent with which assessment? a. LOA -1 station b. LSP -1 station c. LMP +1 station d. LSA +1 station

Answer B - The understanding that palpation of the fetal buttocks indicates that the presenting part is the sacrum (S) eliminates two (2) of the possible responses (A & C). The sacrum was palpated on the mother's left side toward her rectum indicating left posterior. When the presenting part is above the ischial spines, the station is negative (-).

Which of the following is NOT a reason to come to labor and birth. A) The patient is 39 weeks with second baby. She has been having contractions for 2 hours. Contractions are getting longer and stronger and closer together. B) The patients says she has noticed greenish fluid leaking from her vagina. She is 41.5 weeks pregnant and not having contractions. C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours. D) The patient has not felt the baby move for 8 hours, despite drinking cold fluids, and nudging the baby with her hand.

C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours.

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: a) Lie b) Presentation c) Attitude d) Position

C) attitude

A woman in labor with her third child is dilated to 7 cm, and the fetal head is at station +1. The client's membranes rupture. What is the nurse's priority intervention? Notify the practitioner. Observe the vaginal opening for a prolapsed cord. Reposition the client on a sterile towel on her left side. Check the fetal heart rate while observing the color of the amniotic fluid.

Check the fetal heart rate while observing the color of the amniotic fluid.

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? Calling the primary healthcare provider Checking the client's reflexes Determining the client's blood type Administering the prescribed intravenous (IV) normal saline

Checking the client's reflexes

To assess uterine contractions the nurse would A) Asses duration from the beginning of the contraction to the peak of the same contraction, frequency by measuring the time between the beginning of one contraction to the beginning of the next contraction. B) Assess frequency as the time between the end of one contraction and the beginning of the next contraction, duration as the length of time from the beginning to the end of contractions, and palpate the uterus for strength C) Assess duration from beginning to end of each contraction. Assess the strength of the contraction by the external fetal monitor reading. Measure frequency by measuring the beginning of one contraction to another. D) Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength.

D) Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength. p. 453

A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing?

Decreased variability.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is −2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time?

Delay pushing until the baby descends further and the mother has a strong urge to push.

On examination, it is noted that a full-term primipara in active labor is right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician?

Descent is progressing well.

The client at 38 weeks of gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client:

Measuring the fundal height.

When describing the role of a doula to a group of pregnant women, the nurse would include which information?

The doula primarily focuses on providing continuous labor support

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude?

The woman is about to deliver the placenta.

Which of the following pictures depicts a fetus in the frank breech position?

WITH BOTH FEET UP!!!

a pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. when reviewing the results, the nurse determines that which results indicate good glucose control? a. 88 mg/dL b. 110 mg/dL c. 120 mg/dL d. 100 mg/dL

a

The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse anticipate being used to evaluate the fetus for potential neural tube defects?

alpha-fetoprotein analysis

Vaginal examination in the laboring client reveals the anterior fontanel is toward the rectum. The nurse should chart that the baby is in which position? a) occipital posterior b) transverse c) occipital anterior d) breech

c) occipital anterior

A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? a) Back b) Abdomen c) Fundus d) Perineum

d) perineum

The patients contractions are every 2 to 3 minutes, lasting 90 seconds, and are very strong. A vaginal examination reveals the client is 9 cm dilated and +2 station with ROP presentation. The nurse can best promote comfort during this transition phase by: a) Applying pressure to the patient's sacrum b) Washing her perineum c) Encouraging her to void d) Placing a cool cloth behind her neck

d) placing a cool cloth behind her neck

Which description of the phases of the second stage of labor is accurate?

Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies

The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next? Ambulating the client to promote circulation Inserting two small-bore intravenous catheters Determining whether the client feels safe at home Ensuring that the client has her glasses to ambulate

Determining whether the client feels safe at home

A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time?

Place a wedge under the woman's side.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

The bladder must be full during the exam.

A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location?

at the umbilicus

a nurse is reviewing the results of 4 clients who have undergone amniocentesis. which client would the nurse recommend that the health care provider see first? a. pt at 34 weeks' gestation w/ gestational diabetes & L/S ratio of 2:1 b. pt at 16 weeks' gestation w/ placenta previa & high Alpha-fetoprotein level c. pt at 36 week gestation with preeclampsia and amniotic fluid negative for bilirubin d. pt at 38 weeks gestation with fetal HR of 110 and green amniotic fluid sample

d

A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurses answer is based on the knowledge that the anterior fontanel closes after birth by: a) 2 months b) 8 months c) 12 months d) 18 months

d) 18mo

Pregnant women should avoid

hot tubs, saunas, whirlpools, and tanning beds.

Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal (ectopic) pregnancy? A painful, tender area in the epigastric region after meals Lower abdominal cramping of 1 week's duration with constipation Leukorrhea or dysuria occurring a few days after the first missed menstrual period A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder

A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? A) Massaging the woman's back B) Changing the woman's position C) Giving the prescribed medication D) Encouraging the woman to rest between contractions

A) Massaging the woman's back

The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick count assessments.

ANS: 2 1. Fetal fibronectin is not related to glucose metabolism. 2. Positive fetal fibronectin levels are seen in clients who deliver preterm. 3. Fetal fibronectin is not related to hypertensive conditions. 4. Fetal fibronectin is not related to fetal distress.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

ANS: 3 1. The frequency of labor contractions decreases. It does not increase. 2. Labor contractions increase in intensity. They do not become milder. 3. This response indicates that the labor contractions are increasing in intensity. 4. This client has slept through the "tightening" and there is no increase in intensity. It is unlikely that she is in true labor.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

ANS: 4 1. Moderate variability is indicative of fetal health, not of hypoxia. 2. A change in variability indicates acidosis, not alkalosis. In this situation, there is no indication of acidosis. 3. During sleep cycles, fetal heart rate variability decreases. 4. Moderate variability is indicative of fetal health.

A client in labor, G2 P1, was admitted 1 hour ago at 2 cm dilated & 50% effaced. She was talkative & excited at that time. During the past 10 minutes she has become serious, closing her eyes & breathing rapidly with each contraction. Which is an accurate nursing assessment of the situation? a. The client had poor childbirth education prior to labor. b. The client is exhibiting an expected behavior for labor. c. The client is becoming hypoxic & hypercapnic. d. The client needs her alpha-fetoprotein levels checked.

Answer B - The multiparous client in the scenario entered the labor suite in the latent phase of labor when being talkative & excited is normal, but after 1 hour she has progressed into the active phase of labor in which being serious & breathing rapidly with contractions is expected behavior.

An obstetrician is performing an amniotomy on a gravid client in transition. Which assessment must the nurse make immediately following the procedure? a. Maternal blood pressure b. Maternal pulse c. Fetal heart rate d. Fetal fibronectin level

Answer C - Amniotomy is the artificial rupture of the amniotic membranes. During the procedure, there is a risk that the umbilical cord may become compressed. Because there is no direct way to assess cord compression, the nurse must assess the fetal heart rate for any adverse changes.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which interpretation should the nurse make in relation to this finding? a. The fetus is becoming hypoxic b. The fetus is becoming alkalotic c. The fetus is in the middle of a sleep cycle d. The fetus has a healthy nervous system

Answer D - Normal situations that can decrease the variability include fetal sleep, administration of CNS depressant medications, & prematurity. A normal situation that can increase the variability is fetal activity.

A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? a. The baby is in the breech position. b. The baby is in the horizontal lie. c. The baby's presenting part is engaged. d. The baby's chin is resting on its chest.

Answer D - The diameter of the fetal head is dependent upon whether or not the head is flexed with the chin on the chest or extended with the chin elevated. When the fetus is in the flexed attitude, with the chin on the chest, the diameter of the fetal head entering the pelvis averages 9.5 cm (the suboccipitobregmatic diameter), whereas is the fetus is in the extended attitude, with the chin elevated, the diameter of the fetal head can be as large as 13.5 cm (the occipitomental diameter). In order for the fetal head to pass through the mother's pelvis, therefore, it is best for the head to be in the flexed attitude.

Following amniotomy, the nurse would implement which important nursing actions? (Select all that apply.) A. Position the mother in lithotomy position for delivery B. Place a clean underpad (chux) on the bed C. Note FHR D. Observe the color & consistency of the amniotic fluid E. Take vital signs every 4 hours to monitor for infection.

Answer: B., C., D., & E

In addition to routine assessment & care, nursing care of a client who is receiving terbutaline (Brethine) to prevent premature labor should include assessing: A. Temperature every 2 hours B. Fetal heart tones every 30 minutes C. Breath sounds every 4 hours D. Deep tendon reflexes every 4 hours

Answer: C.

The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: A) Relieve pain. B) Stimulate uterine contraction C) Prevent infection D) Facilitate rest and relaxation.

B) Stimulate uterine contraction

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, fullterm gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal?

Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions.

A client at 24 weeks' gestation is admitted in early labor. What should the nurse take into consideration regarding this client's early gestation? If contractions are regular, labor cannot be stopped effectively. Birth at this gestational age usually results in a severely compromised neonate. Attempts will be made to sustain the pregnancy for 2 or 3 more weeks to ensure neonatal survival. Infants born at 30 to 34 weeks' gestation have a low morbidity rate because of advances in neonatal health care.

Birth at this gestational age usually results in a severely compromised neonate.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. if the client progresses from preeclampsia to eclampsia, the nurse's first action should be to:

Clear and maintain an open airway.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times?

For 1 minute immediately after contractions.

The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? From the end of one contraction to the end of the next contraction From the end of one contraction to the beginning of the next contraction From the beginning of one contraction to the end of the next contraction From the beginning of one contraction to the beginning of the next contraction

From the beginning of one contraction to the beginning of the next contraction

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective?

Provide direct sacral pressure.

What nursing interventions will be most helpful to this client at this time?

Reassuring the client & repositioning her on her left side may help with rotation of the fetal head from ROP to an ROA/LOA position. Continue to assess contractions and maternal response to them. Encourage relaxation. Laboring in hands and knees position for several contractions, pelvic rocking and tailor sitting position have been reported to be helpful for rotation and descent of the fetus.

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following?

Scapula.

A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur? Sixth Twelfth Sixteenth Eighteenth

Sixth

A nurse is teaching a class of pregnant couples the most therapeutic breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach?

Slow chest breathing.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean?

The fetal head has entered the true pelvis

Leading a discussion among couples who are thinking about getting pregnant, the nurse stresses that preconception counseling helps to identify risks and encourages modification by the couple before conception. The nurse considers the discussion successful when the couples realize that the greatest risk to the embryo is:

between 17 and 56 days after conception.

Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and delivery. The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?

between 24 and 28 weeks' gestation

Maternity nurse often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a) Music supplied by the support person has to be discouraged because it could disturb others and upset the hospital routine b) Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time c) Effleurage is permissible but counter pressure is almost always counterproductive d) Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins

d) Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins

A nurse is providing care to a pregnant client who is 9 weeks gestation. The client reports that her breasts have become quite tender. She says, "I know my breasts are going to get bigger, but I didn't think that it would be uncomfortable." The nurse offers suggestions to address this discomfort, based on the understanding that this change is the result of which hormones? Select all that apply.

estrogen and progesterone

The client observes the vaginal birth of her first born child by looking in the mirror. She says that after the birth of the baby's head, with the face looking at the floor the baby turned its head to the right on its own, without being touched. The nurse tells the client that this is a normal mechanism called: a) external rotation b) flexion c) extension d) internal rotation

external rotation

When providing preconception care to a client, the nurse would identify which medication as being safe to continue during pregnancy?

famotidine

To adequately care for a laboring woman, the nurse should know which stage of labor varies the most in length? first second third foruth

first

A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond? "What activities does your job entail?" "How do you feel about continuing to work?" "Most women work throughout their pregnancies." "Usually women quit work at the start of their third trimester."

"What activities does your job entail?"

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first?

"You sound frightened."

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 health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?

A softening of the cervix

Select ALL that are true about post dates pregnancy. A) After the due date, women should have assessments of fetal well beings which could include fetal movement counting, biophysical profile and non stress test. B) All women should be induced within a few days part their due date. C) Risks associated with going past 42 weeks gestation include a large baby, low amniotic fluid, meconium aspiration syndrome, and fetal distress in labor. D) An amniotic fluid index of less than 8 has been associated with a higher incidence of Apgar scores less than 7 at 5 minutes.

A) After the due date, women should have assessments of fetal well beings which could include fetal movement counting, biophysical profile and non stress test. C) Risks associated with going past 42 weeks gestation include a large baby, low amniotic fluid, meconium aspiration syndrome, and fetal distress in labor.

A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.

ANS: 4 1. The expected outcome from the administration of Cervidil is an increase in the Bishop score. 2. A fetal heart rate of 152 is within normal limits and not significantly different from the original baseline of 156. 3. A respiratory rate of 24 is not a contraindication to the administration of prostaglandins for cervical ripening. 4. A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication. TEST-TAKING TIP: A frequency of 1 minute, even if the duration were 30 seconds, would mean that there were only 30 seconds when the uterine muscle was relaxed. This short amount of time would not provide the placenta with enough time to be sufficiently perfused. Fetal bradycardia is a likely outcome to such a short frequency period.

A client in labor at 39 weeks' gestation is told by the primary healthcare provider that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth? Gonorrhea Chlamydia Chronic hepatitis Active genital herpes

Active genital herpes

A pregnant woman is admitted in active labor. What should the nurse instruct her coach to do when the client complains of back pain? Position her with her legs elevated. Apply pressure to the sacrum during contractions. Encourage performance of a panting-breathing pattern. Encourage her to do Kegel exercises between contractions.

Apply pressure to the sacrum during contractions.

A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization

Arabic woman.

A nulliparous client was admitted to the birthing unit 9 hours ago. She progressed from 3 cm and 0 station to 6 cm and +1 station, but has not made any additional progress for almost 2 hours. FHR is in the normal baseline range w/moderate variability. There are no decelerations. Contractions are presently every 3 minutes, 40 seconds duration & of strong intensity. Following the vaginal exam, what other assessments will you make at this time?

Assess the contraction frequency, duration and intensity, and compare this to previous contractions. A common cause of nonprogressive labor is hypotonic uterine dysfunction or poor contraction quality. In addition, assess fetal and maternal response to contractions to detect distress in the fetus and tension and anxiety in the mother. Maternal psyche can also impact labor progress.

A pregnant client arrives on the birthing unit from the emergency department with frank blood running down both legs and a reported low blood pressure. What is the priority nursing intervention? Assessing fetal heart tones Assessing for a prolapsed cord Starting an intravenous (IV) infusion Inserting a uterine pressure catheter

Assessing fetal heart tones

A laboring client experiences a spontaneous rupture of membranes. What is the nurse's priority? Assessing the fetal heart rate Estimating the amount of fluid Assessing the characteristics of the fluid Repositioning the client to a side-lying position

Assessing the fetal heart rate

A client is admitted to the labor and delivery unit with contractions that are 3-5 minutes apart, lasting 60-70 seconds. She reports that she is leaking fluid. A vaginal exam reveals that her cervix is 80 percent effaced and 4 cm dilated and a -1 station. The nurse knows that the client is in which phase and stage of labor? A) Latent phase, First Stage B) Active Phase of First Stage C) Latent phase of Second Stage D) Transition

B) Active Phase of First Stage Second stage = full dilation until birth

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A) Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B) Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours C) Lull: No contractions; dilation stable; duration of 20 to 60 minutes D) Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 3-4 hours

B) Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours

Which of the following is true with respect to chorioamninitis? (See power point Labor Complications part 4) A) If a woman has chorioamnionitis she will be treated with penicilin and cefotetan. B) Most often chorioamnionitis is caused by pathogens such as GBBS, pneumococci, and CMV. C) Once a woman who has had chorioamnionitis has delivered the antibiotics will be stopped. D) An epidural can cause maternal fever and fetal tachycardia.

D) An epidural can cause maternal fever and fetal tachycardia.

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? (Select all that apply.)

Ballottement. Chadwick's sign. Uterine enlargement. Braxton Hicks contractions.

A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? Face Brow Breech Shoulder

Breech

As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations with loss of variability is nonreassuring and is associated with A) Cord compression B) Hypotension C) Hypoxemia/acidemia D) Maternal drug use.

C) Hypoxemia/acidemia

After the removal of a hydatidiform mole, the nurse assesses the client's laboratory data during a follow-up visit. The nurse notes that a prolonged increase of the serum human chorionic gonadotropin (hCG) level is a danger sign. Which condition is this client at increased risk of developing? Uterine rupture Choriocarcinoma Hyperemesis gravidarum Disseminated intravascular coagulation (DIC)

Choriocarcinoma

A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? Hydatidiform mole Vena cava syndrome Marginal placenta previa Complete abruptio placentae

Complete abruptio placentae

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which?

Compression of the vena cava

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states that it:

Connects the umbilical vein to the inferior vena cava

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description?

Contractions lasting 1 minute followed by a 120-second rest period.

A pregnant woman brings a list of her routine medications to her first prenatal visit. The nurse would be most concerned about any medications classified in which risk category? A B C D

D

Your client has been on magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client? A) Absence of uterine bleeding in the postpartum period B) A fundus firm below the level of the umbilicus C) Scant lochia flow D) A boggy uterus with heavy lochia flow

D) A boggy uterus with heavy lochia flow

A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments? Report the findings because the client needs immediate intervention. Document the results because they are expected at 20-weeks' gestation. Record the findings in the medical record because they are not within the norm but are not critical. Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.

Document the results because they are expected at 20-weeks' gestation.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? Taking exogenous insulin stimulates fetal growth. Consuming more calories covers the insulin secreted by the fetus. Extra circulating glucose causes the fetus to acquire fatty deposits. Fetal weight gain increases as a result of the common response of maternal overeating.

Extra circulating glucose causes the fetus to acquire fatty deposits.

Immediately after a delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding? Fetal body flexion or extension Maternal age, body frame, and weight Maternal and paternal ethnic backgrounds Maternal parity and gravidity

Fetal body flexion, or extension

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure?

Fetal heart rate.

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply

Fetal heart rate. Contraction pattern. Vital signs.

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into?

Fetal position.

The nurse is caring for a pregnant client with type 1 diabetes. Which complication is the result of type 1 diabetes? Increased risk of hypertensive states Abnormal placental implantation Excessive weight gain because of increased appetite Decreased amount of amniotic fluid as the pregnancy progresses

Increased risk of hypertensive states

A 36-year-old woman comes to the emergency department complaining of severe abdominal cramping and heavy bleeding. She informs the nurse that she is 10 weeks pregnant. Cervical examination reveals heavy bleeding; the cervical as is open and tissue is present. Which type of abortion is the client experiencing? Missed Complete Inevitable Threatened

Inevitable

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate?

Inform the mother that the rate is normal.

Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor?

Inquire regarding the woman's pain level.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions is recommended prior to performing this assessment?

Insert an internal fetal monitor electrode.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition does the nurse suspect that this result indicates? Cystic fibrosis Phenylketonuria Down syndrome Neural tube defect

Neural tube defect

The nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located? At the level of the umbilicus One fingerbreadth above the umbilicus Above and to the right of the umbilicus One or two fingerbreadths below the umbilicus

One or two fingerbreadths below the umbilicus

A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. Which breathing pattern should the nurse instruct the patient to adopt? Take slow, deep breaths Hold her breath and push with each contraction Breathe faster than usual with long cleansing breaths Pant and then exhale through the mouth with pursed lips

Pant and then exhale through the mouth with pursed lips

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? True labor Placenta previa Partial abruptio placentae Abdominal muscular injury

Partial abruptio placentae

A nurse in labor room is preparing to care for pt. with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to monitor the pitocin infusion closely provide pain relief measures prepare the client for an amniotomy promote ambulation every 30 mins

provide pain relief measure

At 16 weeks' gestation, the fundus is

s midway between the symphysis pubis and umbilicus.

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and decreased serum haptoglobin. The nurse notifies the physician because the laboratory results are indicative of: A) Eclampsia. B) Idiopathic thrombocytopenia. C) Disseminated intravascular coagulation (DIC). D) HELLP syndrome.

D) HELLP syndrome.

A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which information?

Further testing will be required to confirm any diagnosis

The nurse is assessing a client with worsening preeclampsia. What is the most significant clinical manifestation of severe preeclampsia? Polyuria Vaginal spotting Proteinuria of 3+ Blood pressure of 130/80 mm Hg

Proteinuria of 3+

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery?

. Massages the perineum with mineral oil.

A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. Which factor does the nurse suspect precipitated this preterm labor? Android pelvis Incompetent cervix First-time pregnancy Antiseizure medication

Incompetent cervix

The most intense portion of the uterine contraction is termed the: increment decrement acme peak

acme

on the first prenatal visit, examination of the woman's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. the nurse documents this findings as: a. goodell's sign b. woman's sign c. Chadwick's sign d. Hagar's sign

c

The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: a)blowing b) slow chest c) shallow d) accelerated-decelerated

a) blowing

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated:

"I took a shower about a half hour ago. The contractions seem to hurt more since I finished."

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."

A nurse teaches warning signs that should be reported throughout prgenancy. Which statement by the client indicates an udnerstanding of the prenatal instructions? "I'll call the clinical if I have abdominal pain" "Mild, irregular contractions mean that my labor is starting" "I need to call the clinic if my ankles start to swell at night" A whitish vaginal discharge means that I'm getting an infection"

"I'll call the clinical if I have abdominal pain"

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following?

"The baby is almost crowning."

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which would indicate successful learning?

"The iron is needed for the red blood cells."

After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's bestresponse? "It's premature separation of a normally implanted placenta." "Your placenta isn't implanted securely in place on the uterine wall." "You have premature aging of a placenta that is implanted in your uterine fundus." "The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."

"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

"The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."

A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which of the following responses, if made by the student, indicates an understanding of the anatomy of this structure?

"The uterus weighs about 2 ounces."

During a follow-up appointment, a client at 21 weeks' gestation is diagnosed with hyperemesis gravidarum. The client says, "Why is this happening to me? I don't know whether I can go on like this." What is the ideal response by the nurse? "Are you saying that you want to schedule an abortion?" "This must be physically and emotionally challenging for you." "We're doing the best we can here, so please be patient with us." "There are dietary changes and medications available that can ease the nausea."

"This must be physically and emotionally challenging for you."

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? (Select all that apply.)

1. Allows for fetal movement. 2. Is a measure of kidney function. 3. Surrounds, cushions, and protects the fetus. 4. Maintains the body temperature of the fetus.

A nurse is monitoring a client in labor who is receiving pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes

1. stop of pitocin infusion 2. perform a vaginal examination 3. reposition the client 4. check the client's blood pressure and heart rate 5. administer oxygen by face mask at 8 to 10 L/min

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now:

10 cm dilated, 100% effaced, and +5 station

A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make:

11 52 33 44 25

A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this clinical finding to occur? 8th week of pregnancy 10th week of pregnancy 12th week of pregnancy 18th week of pregnancy

12th week of pregnancy

A client who is in her first trimester is anxious to have an ultrasound at each visit. The nurse explains that it is not necessary and schedules a second ultrasound to be performed when she is about:

18 to 20 weeks pregnant.

women should be tested for gestational diabetes between ?

24-28 weeks

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?

28 cm

Assessment for edema is typically done between

29-36 weeks

Backache and leg cramps are more common in

2nd trimester

A pregnant woman comes to the clinic for a visit. This is her third pregnancy. She had a miscarriage at 12 weeks and gave birth to a son, now 3 years old,at 32 weeks. Using the GTPAL system, the nurse would document this woman's obstetric history as:

30111

With regard to the use of tocolytic therapy to suppress premature uterine activity, nurses should be aware that: A) Its most important function is to afford the opportunity to administer antenatal glucocorticoids. B) The drugs can be given efficaciously up to the designated beginning of term at 37 weeks. C) If the client develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given. D) There are no important maternal (as opposed to fetal) contraindications.

A) Its most important function is to afford the opportunity to administer antenatal glucocorticoids.

A woman in labor has just received an epidural block. The most important nursing intervention is to: A) Limit parenteral fluids. B) Monitor the fetus for possible tachycardia C) Monitor the maternal blood pressure for possible hypotension. D) Monitor the maternal pulse for possible bradycardia

C) Monitor the maternal blood pressure for possible hypotension.

The nurse providing care for a woman with preterm labor on terbutaline would include which intervention to identify side effects of the drug? A) Assessing for dyspnea and crackles B) Assessing for bradycardia C) Assessing deep tendon reflexes (DTRs) D) Assessing for hypoglycemia

A) Assessing for dyspnea and crackles

With regard to fetal positioning during labor, nurses should be aware that: A) Birth is imminent when the presenting part is at +4 to +5 cm, below the spine. B) Engagement is the term used to describe the beginning of labor. C) The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. D) Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal.

A) Birth is imminent when the presenting part is at +4 to +5 cm, below the spine. p. 378 • Primary Powers (involuntary uterine contractions) = term used to describe the beginning of labor. • The largest transverse diameter of the presenting part is the biparietal or occipitomental diameter. • Station = measure of the degree of descent of the presenting part of the fetus through the birth canal.

Which presentation is described accurately in terms of both presenting part and frequency of occurrence? A) Cephalic: occiput; at least 95% B) Cephalic: cranial; 80% to 85% C) Shoulder: scapula; 10% to 15% D) Breech: sacrum; 10% to 15%

A) Cephalic: occiput; at least 95% p. 377

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

ANS: 1 1. The nurse would expect the woman to be 2 cm dilated. 2. At 4 cm, the woman is entering the active phase of labor. 3. At 8 cm, the woman is in the transition phase of labor. 4. At 10 cm, the woman is in the second stage of labor.

A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? Placenta previa Precipitous birth Abruptio placentae Breech presentation

Abruptio placentae

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. What is the priority nursing action? Administering oxygen Elevating the head of the bed Drawing blood for a hematocrit level Giving an intramuscular analgesic

Administering oxygen

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply.

After vaginal exams. Before administration of analgesics. Periodically at the end of a contraction. Before ambulating.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which assessment must the nurse make at this time? a. The relationship between the decelerations & the labor contractions b. The maternal blood pressure c. The gestational age of the fetus d. The placement of the fetal heart electrode in relation to the fetal position

Answer A - Decelerations are defined by their relationship to the contraction pattern. It is essential that the nurse determine which of the three (3) types of decelerations is present. Early decelerations mirror contractions, late decelerations develop at the peak of contractions & return to baseline well after contractions are over, & variable decelerations can occur at any time & are unrelated to contractions.

The nurse is performing a vaginal exam on a client in labor. The client is found to be 5cm, 90% and -2. What has the nurse palpated? a. A thin cervix b. Bulging fetal membranes c. Head at the pelvic outlet d. Closed cervix

Answer A - During pregnancy & early labor, the cervix is closed, long, & thick. During the labor process, however, the cervix changes shape, becoming paper thin& dilating to 10 cm. This is a universal finding. No matter how tall or short, young or old a woman is, her cervix will dilate to 10 cm & efface 100% if she has a vaginal delivery.

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which position should the nurse assist the client into? a. Fetal position b. Lithotomy position c. Trendelenburg position d. Lateral recumbent position

Answer A - In order for the anesthesiologist to be able to insert the epidural catheter into the epidural space, the client must be placed in either the fetal position or sitting with her chin on her chest & her back convex. In both of those positions, the client's vertebrae separate, providing the anesthesiologist access to the required space.

A client in labor is talkative and happy. How many centimeters dilated would a labor nurse suspect that the client is at at this time? a. 2 cm b. 4 cm c. 8 cm d. 10 cm

Answer A - In the latent phase of labor, clients are often very excited because labor has finally begun. They frequently are very talkative & easily distracted from the contractions.

A gravid client at term calls the labor suite at 7pm questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: a. "At 5pm, the contractions were about 5 minutes apart. Now they're about 7 minutes apart." b. "I took a walk at 5pm, & now I talk through my contractions easier that I could then." c. "I took a shower about half an hour ago. The contractions seem to hurt more since I finished." d. "I had some tightening in my belly late this afternoon, & I still feel it after waking up from my 2-hour nap."

Answer C - As labor progresses, the frequency, duration, & intensity of contractions increase. The client utilized comfort measures (showering) which actually intensified her contractions. She should be seen.

The nurse may help a client with a fetus in a ROP position by avoiding which action: A. Positioning her on her left side B. Positioning her on her right side C. Helping her walk around the room D. Assisting her to a knee-chest position

Answer: B.

The pregnant client is receiving oxytocin (Pitocin) to induce labor. The nurse should monitor the client for which adverse maternal effects? A. Bradycardia B. Decreased urine output C. Dehydration D. Jaundice E. Uterine hyperstimulation.

Answer: B. & E.

The client who has had a previous cesarean birth asks about vaginal birth after cesarean (VBAC). The nurse concludes that which factors from her history in a contraindication for VBAC? A. Previous cesarean was for breech presentation B. Client had a classic uterine incision C. The abdominal incision was vertical rather than transverse D. An induction of labor is planned for this delivery

Answer: B. - a classical incision involves the upper uterine segment & is more likely to separate or rupture with subsequent uterine contractions

A laboring client reports low back pain. Which intervention should the nurse recommend to the client's coach to promote the most comfort for this client? Instruct her to flex her knees. Place her in the supine position. Apply pressure to her back during contractions. Perform neuromuscular control exercises with her.

Apply pressure to her back during contractions

A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and is 60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood from the vagina. The uterus is irritable upon palpation and does not relax fully between contractions. What is the initial nursing action? Transporting the client for a cesarean birth Checking the perineum for rupture of membranes Changing the underpad and positioning the client on her left side Assessing the fetal heart rate, uterine activity, and blood pressure

Assessing the fetal heart rate, uterine activity, and blood pressure

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply.

Assess fetal heart rate. Infuse 1,000 mL of Ringer's lactate.

A pregnant woman who is 26 weeks pregnant arrives for a follow-up visit. Which assessments, in addition to measuring fundal height and fetal heart rate, would the nurse expect to complete? Select all that apply.

blood pressure weight urine testing blood glucose level

The role of the nurse with regard to informed consent is to: A) Inform the client about the procedure and have her sign the consent form. B) Act as a client advocate and help clarify the procedure and the options. C) Call the physician to see the client D) Witness the signing of the consent form.

B) Act as a client advocate and help clarify the procedure and the options.

Choose ALL that are true about post dates pregnancy. A) All women should be induced within a few days past their due date. B) Additional tests of fetal well being are ordered after the due date and include a nonstress test, fetal movement counting, and biophysical profile or Amniotic fluid Index. C) A low amniotic fluid index of less than 8 is associated with a higher incidence of low Apgar scores of 7 or lower. D) Post dates pregnancy is associated with larger babies, prolonged labor, fetal distressi in labor, meconium aspiration syndrome and more cesarean births.

B) Additional tests of fetal well being are ordered after the due date and include a nonstress test, fetal movement counting, and biophysical profile or Amniotic fluid Index. D) Post dates pregnancy is associated with larger babies, prolonged labor, fetal distressi in labor, meconium aspiration syndrome and more cesarean births.

The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: A) Fetal hypoxemia B) Fetal sleep cycles C) Altered cerebral blood flow. D) Umbilical cord compression.

B) Fetal sleep cycles p. 428

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should: A) Notify the woman's primary health care provider immediately B) Prepare to administer an oxytocic to stimulate uterine activity C) Document the findings because they reflect the expected contraction pattern for the active phase of labor. D) Prepare the woman for the onset of the second stage of labor.

C) Document the findings because they reflect the expected contraction pattern for the active phase of labor.

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care? A) Telling the client to relax and that it won't hurt much B) Limiting the number of procedures that invade her body C) Reassuring the client that as the nurse you know what is best D) Allowing unlimited care providers to be with the client

B) Limiting the number of procedures that invade her body

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? A) Sitting B) Squatting C) Side-lying D) Semirecumbent

B) Squatting p. 385

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: A) The resting tone between contractions is described as either placid or turbulent B) The examiner's hand should be placed over the fundus before, during, and after contractions. C) The frequency and duration of contractions is measured in seconds for consistency D) Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.

B) The examiner's hand should be placed over the fundus before, during, and after contractions. p. 424

A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate? Hypertension Hypoglycemia Chilling and shivering Bleeding and infection

Bleeding and infection

Which nursing assessment is most important for a large-for-gestational-age (LGA) infant of a diabetic mother (IDM)? Temperature less than 98° F (36.6° C) Heart rate of 110 beats/min Blood glucose level less than 40 mg/dL (2.2 mmol/L) Increasing bilirubin during the first 24 hours

Blood glucose level less than 40 mg/dL (2.2 mmol/L)

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply

Bulging perineum. Increased bloody show. Uncontrollable urge to push.

The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions? A) "I will not experience mood swings since I was only at 10 weeks of gestation." B) "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months." C) "I should eat foods that are high in iron and protein to help my body heal." D) "I should expect the bleeding to be heavy and bright red for at lease 1 week."

C) "I should eat foods that are high in iron and protein to help my body heal."

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: A) Notify the care provider. B) Assist with amnioinfusion C) Change the woman's position D) Insert a scalp electrode.

C) Change the woman's position p. 431-432; see box 17-4

Your patient is a nulliparous woman, requesting pain relief. You examine her and she is 8 cm. What is the best option for pain relief at this point? A) Demerol B) Spinal C) Epidural D) Stadol

C) Epidural

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? A) She is too far dilated B) She is anemic. C) She has thrombocytopenia D) She is septic

C) She has thrombocytopenia

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) Suppress uterine contractions. B) Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy. C) Stimulate fetal surfactant production. D) Reduce maternal and fetal tachycardia associated with ritodrine administration

C) Stimulate fetal surfactant production.

The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat: A) Fetal tachycardia. B) Fetal bradycardia. C) Variable decelerations D) Late decelerations.

C) Variable decelerations p. 432 & 436; see box 17-5

The hormone that acts to facilitate the development of uterine contractions is: A. Estrogen B. Pitocin C. Prostaglandin D. Progesterone is based on the knowledge that:

C. Prostaglandins

What is the optimal method for the nurse to use to assess blood loss in a client with placenta previa? Count or weigh perineal pads Monitor pulse and blood pressure Check hemoglobin and hematocrit values Measure or estimate the height of the fundus

Count or weigh perineal pads

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result?

Cover the woman's perineum with a sheet.

A nurse is caring for a client during an ultrasonogram. Which parameters does the nurse expect to be used in the determination of pregnancy dates? Occipital frontal diameter at term Crown-to-rump measurement until 11 weeks Biparietal diameter of 12 cm or more at term Diagonal conjugate between 26 and 37 weeks

Crown-to-rump measurement until 11 weeks

Which of the following is NOT a reassuring component of the fetal heart rate A) FHR of 114 B) Accelerations of the FHR C) Moderate Variability D) Absent FHR Variability

D) Absent FHR Variability p. 428

The nurse providing care for the laboring woman should understand that accelerations with fetal movement: A) Are caused by umbilical cord compression B) Are caused by uteroplacental insufficiency C) Warrant close observation D) Are reassuring.

D) Are reassuring. p. 427

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: A) Prepare the woman for imminent birth B) Notify the woman's primary health care provider. C) Document the characteristics of the fluid. D) Assess the fetal heart rate and pattern.

D) Assess the fetal heart rate and pattern.

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: A) Lie. B) Position. C) Presentation. D) Attitude.

D) Attitude. • Lie = relationship between the longitudinal axis of fetus and mother • Position = relationship of the presenting part to the 4 quadrants of the mother's pelvis, ie 3 letter abr: 1.) R or L 2.) O, S, M or Sc (Occiput, Sacrum, Mentum, SCapula) 3.) A, P, or T (Anterior, Posterior, Transverse) • Presentation = presenting part that overlies pelvic inlet

Which of the following is true about placenta previa. A) The bleeding from placenta previa usually occurs late in pregnancy at term. B) In evaluating the bleeding, a vaginal exam would be done to determine the cause of the bleeding. C) Symptoms of placenta previa are painful frequent contractions and bright red vaginal bleeding D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester.

D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester.

A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. What intervention would be the top priority? A) Starting oxygen by face mask B) Preparing the woman for a cesarean birth C) Covering the cord in sterile gauze soaked in saline D) Placing the woman in the knee-chest position

D) Placing the woman in the knee-chest position

The factors that affect the process of labor and birth, known commonly as the five Ps, include all EXCEPT: A) Passageway. B) Powers. C) Passenger. D) Pressure.

D) Pressure. :: The 5 P's are: 1. Powers (contractions) 2. Passengers (fetus & placenta) 3. Passageway (birth canal) 4. Position (of the mother) 5. Psychological Response

Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to: A) Increase amniotic fluid volume. B) Stimulate the amniotic membranes to rupture. C) Enhance uteroplacental perfusion in an aging placenta. D) Ripen the cervix in preparation for labor induction.

D) Ripen the cervix in preparation for labor induction.

The nurse has received a report about a woman in labor. The woman's last vaginal examination was recorded as 4, 80%, and -2. The nurse's interpretation of this assessment is that: A) The cervix is dilated 4 cm, it is effaced 80%, and the presenting part is 2 cm below the ischial spines B) The cervix is effaced 4 cm, it is dilated 80%, and the presenting part is 2 cm below the ischial spines. C) The cervix is effaced 4 cm, it is dilated 80%, and the presenting part is 2 cm above the ischial spines D) The cervix is 4 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines

D) The cervix is 4 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines

A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A)a form of biofeedback to enhance bearing down efforts during delivery B) light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus c) the application of pressure to the sacrum to relieve a backache D) performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

D) light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus

A client who has missed two menstrual periods arrives at the prenatal clinic with vaginal bleeding and one-sided lower quadrant pain. Which condition does the nurse suspect? Placenta previa Ectopic pregnancy Incomplete abortion Rupture of a graafian follicle

Ectopic pregnancy

At her prenatal visit a client reports that she cannot find any shoes that are comfortable. Assessment of her legs reveals dependent edema. The nurse suggests that the client attempt which actions to help reduce the edema? Select all that apply.

Elevate feet and legs when sitting or lying. Avoid foods high in sodium, sugar, and fats. Drink 6 to 8 glasses of water each day.

The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history? Cardiac disease Hyperthyroidism Gestational hypertension Cephalopelvic disproportion

Gestational hypertension

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor?

Extension.

The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see?

Fetal heart acceleration

What is the desired outcome for the intrapartum client during the third stage of labor? Absence of discomfort Firmly contracted uterine fundus Efficient fetal heart beat-to-beat variability Maternal respiratory rate within the expected range

Firmly contracted uterine fundus

Which description of the four stages of labor is correct for both definition and duration? A: First stage: onset of regular uterine contractions to full dilation: less than 1 hour to 20 hours B: Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours C: Third stage: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first timer) D: Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

First stage: onset of regular uterine contractions to full dilation: less than 1 hour to 20 hours

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

G = 2, T = 1, P = 0, A = 0, L = 1

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform? Select all that apply

Give the woman a back rub.

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 should document which gravida and para status on this client?

Gravida II, para I

The patient is in labor. The nurse review the copy of her antepartum records sent by her O.B's office. The records indicate that her pelvic sturcture is ________ the type most favorable for vaginal delievery

Gynecoid

The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? Hemorrhage Dehydration Hypertension Subinvolution

Hemorrhage

the nurse is reviewing the laboratory test results of a pregnant client. which finding would alert the nurse to the development of HELLP syndrome? a. elevated platelet count b. hyperglycemia c. elevated liver enzymes d. leukocytosis

c

The nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when the fetal heart rate shows what during contractions? Late decelerations Early accelerations Variable decelerations Prolonged accelerations

Late decelerations

A pregnant client at 37 weeks' gestation is taught the signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report what? Lower back pain White vaginal discharge Irregular strong contractions Leakage of fluid from the vagina

Leakage of fluid from the vagina

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat?

Left lower quadrant.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings?

Left occipital anterior (LOA)

The nurse is caring for a client in labor whose fetus is in the breech presentation. Which would be an expected finding for this client? Hemorrhagic shock Increased blood pressure Compression of the cord Meconium in the amniotic fluid

Meconium in the amniotic fluid

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction?

Monitor for signs of rectal pressure.

Prolapsed umbilical cord. Notified the HCP. Place the folloing in order? Moving the presenting part off the cord Checking fetal heart rate Placing the client in Trandelenberg position Administering oxygen by facemask

Moving the prsenting part off the cord Placing the client in Trandelenberg position Administering oxygen by facemask Checking fetal heart rate

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply.

Muscle relaxation. Pelvic rocking. Abdominal massage.

know this

Nagele's rule can be used, which involves subtracting 3 months and then adding 7 days to the first day of the LMP.

An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the fetus is in what position? Breech Transverse Occiput anterior Occiput posterior

Occiput posterior

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions?

Occiput posterior.

The nurse is providing acupressure to provide pain relief to a woman in labor. Where is the best location for the acupressure to be applied? Select all that apply.

On the medial aspect of the lower leg.\ At the top one third of the sole of the foot

Which information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy? Labor and birth Signs and symptoms of complications Role transition into parenthood and its acceptance Physical and emotional changes resulting from pregnancy

Physical and emotional changes resulting from pregnancy

A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented? Precipitous vaginal delivery Prolonged transitional phase Primigravida primary delivery Normal spontaneous vaginal delivery

Precipitous vaginal delivery

Which of the following pictures depicts a fetus in the ROP position?

RIGHT SIDE..HEAD DOWN,,,,FACING OUTWARDS OF TUMMY

What nursing action is the priority for a client in the second stage of labor? Check the fetus's position. Administer medication for pain. Promote effective pushing by the client. Explain that breastfeeding can start right after birth.

Promote effective pushing by the client.

The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time?

Provide caring labor support.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do

Provide caring labor support.

The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care?

Provide the woman with a long-sleeved hospital gown.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta:

Provides an exchange of nutrients and waste products between the mother and the fetus

The childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do?

Push down with an open glottis.

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions? Relax by closing her eyes Push with her glottis open Blow to slow the birth process Pant to prevent cervical edema

Push with her glottis open

A client who is 38 weeks pregnant presents to the labor unit for a nonstress test (NST). The resulting fetal monitor strip is shown. How does the nurse interpret this finding? (picture) Negative because of the lack of contractions Nonreassuring; fetal heart rate lacks variability Reassuring; fetal heart rate accelerates with movement Positive; demonstrates decelerations with fetal movement

Reassuring; fetal heart rate accelerates with movement

While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse's most appropriate action at his time? Call the practitioner to prepare for an imminent birth. Turn the mother on her left side to increase venous return. Record the fetal response to contractions and continue to monitor the heart rate. Document the fetal heart rate abnormality and monitor the fetal heart rate continuously.

Record the fetal response to contractions and continue to monitor the heart rate

While admitting a woman to a labor unit, the nurse needs to obtain information from her regarding all of the following except:

Rubella titer

-Upon checking a laboring patient, the nurse determines her cervix to be 50% effaced and dilated to 3cm What would be the lease appropriate action at this time?

Send the patient home, she is not in true labor

A client at 42 weeks' gestation is scheduled for induction of labor. The nurse begins the induction with a piggyback infusion of 15 units of oxytocin. Which clinical finding requires the nurse to discontinue the oxytocin infusion? Contractions that occur every 3 minutes and lasting 60 seconds Elevation of blood pressure from 110/70 to 135/85 mm Hg during the last 30 minutes Rupture of membranes with amniotic fluid that contains threads of blood and mucus Several late fetal heart rate decelerations that return to baseline after the contraction is over

Several late fetal heart rate decelerations that return to baseline after the contraction is over

A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She has gained 50 lb (22.7 kg) during the pregnancy, and her face and extremities are edematous. Which complication is this client experiencing? Eclampsia Severe preeclampsia Chronic hypertension Gestational hypertension

Severe preeclampsia

A client being prepared for surgery because of a ruptured tubal pregnancy complains that she feels lightheaded. Her pulse is rapid, and her color is pale. Which condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy? Shock Anxiety Infection Hyperoxygenation

Shock

The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of most concern to the nurse? Continued bloody show Cervical dilation of 4 cm Contractions every 4 minutes Spontaneous rupture of membranes 3 hours ago

Spontaneous rupture of membranes 3 hours ago

A nurse is assessing a woman with a probable ruptured tubal pregnancy. What clinical manifestation requires immediate intervention? Abdominal distention Intermittent abdominal contractions Dull, continuous upper-quadrant abdominal pain Sudden onset of knifelike pain in one of the lower quadrants

Sudden onset of knifelike pain in one of the lower quadrants

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?

Tell the client that these are common and they may occur throughout the pregnancy.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother?

The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate?

The baby is going to be born very soon. It is really too late for an epidural."

A nurse assesses the frequency of a client's contractions by timing them from the beginning of a contraction until when? The uterus starts to relax The end of a second contraction The uterus has relaxed completely The beginning of the next contraction

The beginning of the next contraction

A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the patient at this time? The cervix dilates and becomes effaced in true labor. Bloody show is the first sign of true labor. The membranes rupture at the beginning of true labor. Fetal movements lessen and become weaker in true labor.

The cervix dilates and becomes effaced in true labor.

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply

Weight gain. Ethnicity and religion. Age. Gravidity and parity.

The nurse has received a report about a woman in labor. The woman's last vaginal examination was recorded as 3cm, 30%, and -2. The nurse's interpretation of this assessment is: A: The cervix is effaced 3cm, dilated 30%, and presenting part is 2cm above the ischial spines B: The cervix is 3cm dilated, effaced 30%, and the presenting part is 2cm above the ischial spines C: The cervix is effaced 3cm, dilated 30%, and the presenting part is 2cm below the ischial spines D: The cervix is dilated 3cm, effaced 30%, and the presenting part is 2cm below the ischial spines

The cervix is 3cm dilated, effaced 30%, and the presenting part is 2cm above the ischial spines

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation?

The client is exhibiting an expected behavior for labor.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply.

The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse

The fetal lie is vertical

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding

The fetus has a healthy nervous system

The client's husband asks you why labor has not progressed very much. How will you answer him?

The most common reasons are decreased contraction quality, shape of the mother's pelvic bones & the way the baby is positioned. "Your baby seems to be facing upward position; that is more difficult to deliver than the usual facing downward position. It may take your wife a little longer to deliver, but there doesn't seem to be any sign of a problem for the baby right now."

The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is:

The most favorable for labor and birth

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion?

The woman talks and laughs during contractions

A client in active labor has requested epidural anesthesia for pain management. The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation? It is the policy of the institution to provide 2 bags of lactated Ringer solution. There is a risk of hypotension, and the large amount of IV fluid reduces this risk. Giving the large amount of IV fluid is a means of hydrating the client when she is unable to drink. The client must be given 500 mL of fluid to ascertain that the line is patent.

There is a risk of hypotension, and the large amount of IV fluid reduces this risk.

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station −2. Which of the following has the nurse palpated?

Thin cervix.

A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect? Missed abortion Inevitable abortion Incomplete abortion Threatened abortion

Threatened abortion

The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? Head compression Maternal hypothyroidism Uteroplacental insufficiency Umbilical cord compression

Uteroplacental insufficiency

While caring for a woman who has had a positive contraction stress test (CST), what complication does the nurse suspect? Preeclampsia Placenta previa Imminent preterm birth Uteroplacental insufficiency

Uteroplacental insufficiency

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women?

Utilizing visual aids like movies and posters during the classes.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status?

Vaginal examination.

The nurse is caring for a client in the first stage of labor, and an external fetal heart monitor is in place. What do the tracings indicate?(picture) Fetal tachycardia Early accelerations Variable decelerations Inadequate long-term variability

Variable decelerations

A G1 P0, 8 cm dilated, is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with an analgesic-potentiating medication. Which of the following medications would the nurse expect to be ordered as the analgesic-potentiating medication?

Vistaril (hydroxyzine). OR PHENERGAN

Physical assessment of a client in active labor reveals that the cervix is dilated 3 to 4 cm and 50% effaced, the fetus is in the right sacrum anterior (RSA) position, and contractions are 5 minutes apart. Where should the nurse place the stethoscope to best locate the fetal heart tones? *picture of abdomen*

a

a pregnant woman tests positive for HBV. what would the nurse expect to administer? A. HBV immune globulin B. valacyclovir C. HBV vaccine D. Acyclovir

a

a nurse is completing a continuing education program about the male & female reproductive organs. after reviewing the information, the nurse demonstrates understanding of the information by identifying which structures as male accessory organs? select all that apply. a. bulbourethral glands b. penis c. vas deferens d. prostate gland e. teste

a c d

a pregnant woman is scheduled for chorionic villus sampling. the nurse is describing the procedure and the potential for complications. when providing care to the patient after testing, the nurse would be alert for which complication as the most common? select all that apply? a. cramping b. vaginal bleeding c. hematoma d. spontaneous abortion e. rupture of membranes

a b

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is: A)1cm above the ischial spine b) 1 fingerbreadth below the symphysis pubis c) 1 inch below the coccyx d) 1 inch below the iliac crest

a) 1cm above the ischial spine

The nurse would anticipate that the parents would have the most difficulty bonding to which of the following infants? a) An infant who sleeps a lot b) An infant who does not resemble either parent c) An infant who is alert and hyperactive d) An infant who has the undesired sex

a) an infant who sleeps a lot

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a) Has recovered from epidural or spinal anesthesia b) Has hidden bleeding underneath her c) Has regained some flexibility d) Is a candidate to go home after 6 hours

a) has recovered from epidural or spinal anesthesia

The most critical nursing action in caring for the newborn immediately after birth is: a) Keeping the airway clear b) Fostering parent-newborn attachment c) Drying the newborn and wrapping the infant in a blanket

a) keeping the airway clear

With regard to nerve block analgesia and anesthesia, nurse should be aware that: a) most local agents are related chemically to cocaine and end in the suffix caine b) local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once c) a pudendal nerve block is designed to relieve pain form uterine contractions d) a pudendal nerve block, if done correctly, does not significantly lessen the bearing down reflex

a) most local agents are related chemically to cocaine adn end in the suffix caine

Which of the following fetal positions is most favorable for birth? a) Vertex presentation b) Transverse lie c) Frank breech presentation d) Posterior position of the fetal head

a) vertex presentation

A potential complication for the mother and fetus is Rh incompatibility; therefore, assessment should include blood typing. If the mother is Rh negative, her antibody titer should be evaluated. If treatment with RhoGAM is indicated, the nurse would expect to administer it at which time?

at 28 weeks

a nurse is reviewing the medical record of a pregnant women and notes that she is gravid 2. the nurse interprets this to indicate the number of: a. preterm births b. pregnancies c. births d. spontaneous abortions

b

after assessing a woman who has come to the clinic, the nurse suspects that the woman is experiencing abnormal uterine bleeding. which statement by the client would support the nurse's suspicions? a. my periods have been unusually long and heavy lately b. I've been having bleeding off and on that's irregular and sometimes heavy c.I get sharp pain in my lower abdomen usually starting soon after my period comes d. I get really irritable and moody about a week before my period

b

in the menstrual cycle, every month the female reproductive system generates an ovum. when the ovum is not fertilized, production of which of the following leads to menstruation? a. another ovum which gains immediately b. progesterone by the corpus lute beginning to decrease c. follicle stimulating hormone by the anterior pituitary d. estrogen the corpus lute begins to decrease

b

Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors? a) Contractions, passageway, placental position and function, pattern of care b) Contractions, maternal response, placental position, psychological response c) Passageway, contractions, placental position and function, psychological response d) Passageway, placental position and function, paternal response, psychological response

c) Passageway, contractions, placental position and function, psychological response

Lithium

category D drug with clear health risks for the fetus and should be avoided during pregnancy

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that lasts 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? a) Encourage the client's coach to continue to encourage breathing exercises b) Encourage the client to continue pushing with each contraction c) Continue monitoring the fetal heart rate d) Notify the physician or the nurse mid-wife

d) notify the physician or the nurse midwife

The nurse is preparing a patient for an epidural anesthetic. The patient's husband says "my sister had medicine put in her back when she had a baby, and she had a headache for a week afterwards." The nurse explains that his sister probably and a spinal anesthetic, and that with regard to headaches, the difference between a spinal and an epidural is that the spinal anesthetic: a) Can lead to hypertension which results in headache b) Use a medication that cuase headache as a side effect c) Lasts longer than an epidural so the side effects are greater d) Penetrates the dura and allows a small amount of cerebrospinal fluid to "leak out," which can cause headache

d) penetrates the dura and allows a small amount of cerebrospinal fluid to "leak out,"which can cause headache

In the transition phase of labor the patient wants to know why she has pain in other places if it is her cervix that is stretching and opening. The nurse understands that the primary reason for the extra discomfort is: a) distention of the vagina b) pressure of the presenting part in the floor of the perineum c) muscle tension in the arms and legs d) referred pain from the uterus

d) referred pain from the uterus

You performed the leopold's maneuver and found the following: breech presentation, fetal back at the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) best in which location? a) Left lower quadrant b) Right lower quadrant c) Left upper quadrant d) Right upper quadrant

d) right upper quadrant

When a client entered the fourth stage of labor? a) When the baby is being expelled b) After the baby is being expelled c) When contractions first reach 60-90 seconds long d) Soon after the placenta is delivered

d) soon after the placenta is delievered

At 36 weeks' gestation, the fundus can be palpated

just below the ensiform cartilage.

A primigravida client tells the nurse that about 2 weeks before going into labor she noticed her breathing became easier, but she had to go to the bathroom more frequently. The nurse tells the client that what she experienced is commonly called:

lightening

Signs that precede labor include (choose all that apply): lightening exhaustion bloody show rupture of membranes decreased fetal movement

lightening, bloody show, rupture of membranes

Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. this nurse documents this as which findings? a. melasma b. straw gravidarum c. line nigra d. vascular spiders

line nigra

Part of the initial prenatal assessment should include the client's immunization history. The nurse informs the client to avoid which type of vaccines while she is pregnant?

live virus vaccine

after teaching a group of pregnant women about breastfeeding, the nurse determines that the teaching was successful when the group identifies which hormone as being inhibited during pregnancy but is important for the production of breast milk after birth? a. progesterone b. gonadotropin-releasing hormone c. prolactin d. placental estrogen

prolactin

Doppler flow study evaluates

the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for chromosomal defects

In leopold's maneuver stop #1, you palpated a soft broad mass that moves with the rest of the body. The correct interpretation of this finding is:

the butt

Regarding how the fetus moves through the birth canal, nurses should be aware that: the fetal attitude describes the angle at which the fetus exits the uterus of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother the normal attitude of the fetus is called general flexion the transverse lie is preferred for vaginal birth

the normal attitude of the fetus is called general flexion

Amniocentesis is performed

the second trimester, usually between 15 and 18 weeks gestation

In preparing for a preconception class, the nurse plans to include a discussion of potential risk factors. Which risk factor would be most important to include?

the use of OTC drugs with teratogens

Her labor is induced. She is receiving oxytocin injection (Pitocin) intravenously. Which of these signs would be indicative of an problematic effect of this medication: fetal heart rate of 155 beats per min appearance of bloody show uterine contractions lasting more than 90 seconds radial pulse rate of 92 bpm

uterine contractions lasting more than 90 seconds

which female reproductive tract structure would the nurse describe to a group of young women as containing rugae it to dilate during labor and birth? a. Fallopian tube b. cervix c. vulva d. vagina

vagina

Blood typing

via blood sample

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the Fallopian tubes. The nurse responds to the client, knowing that the Fallopian tubes:

where fertilization occurs