Exam 1 SSI PQs
A client in labor tells the nurse that she feels a strong urge to push. Physical examination reveals that her cervix is not completely dilated. The nurse tells her not to push yet. What is the rationale for this instruction? a. Early pushing may cause cervical edema and impede fetal descent. b. The nurse-midwife isn't ready to assist her and all staff should be present before pushing begins. c. The fetus hasn't rotated into the proper position. d. Pushing at this time may cause rupture of the membranes.
A) Early pushing may cause edema and impede fetal descent. Pushing (bearing down) before the cervix is completely dilated may cause edema, tissue damage and may impede fetal descent. Telling the client not to push because the nurse-midwife isn't ready to assist is inappropriate and unprofessional. If the cervix were completely dilated, the nurse-midwife could assist the client in changing position to help reposition the fetus. The client's membranes status does not effect if and when a patient should push.
The labor nurse should assess carefully for which adverse reaction to epidural anesthesia? a. Hypotension b. Fetal tachycardia c. Renal toxicity d. Increased variability in the fetal heart rate (FHR)
A) Hypotension Hypotensive crisis may occur after epidural anesthesia administration as the anesthetic agent spreads through the spinal canal, blocking sympathetic innervation. Other signs and symptoms of hypotensive crisis associated with epidural anesthesia may include fetal bradycardia (not tachycardia), decreased (not increased) variability in the FHR, and late decels. Urine retention, not renal toxicity, may occur during the postpartum period.
During the fourth stage of labor, your client should be assessed carefully for: a. uterine atony b. complete cervical dilation c. placental expulsion d. umbilical cord prolapse
A) Uterine atony. Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus's presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The presence of umbilical cord prolapse requires an emergency delivery.
The nurse is aware that one of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor? a. Uterine hyperstimulation b. Elevated blood pressure c. Early decelerations of fetal heart rate d. Water intoxication
A) Uterine hyperstimulation Too many contractions are the most serious adverse effect associated with administering oxytocin. When hyperstimulation occurs, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration.
The nurse is aware that an expected fetal adverse reaction to meperidine (Demerol) during labor is: a. decreased variability. b. bradycardia. c. late decelerations. d. none known
A) decreased variability. Possible fetal adverse reactions include both moderate central nervous system depression and decreased variability. Bradycardia and late decelerations don't occur as a result of meperidine administration.
Which of the following would be the priority nursing diagnosis for a client just diagnosed with an ectopic pregnancy? 1) Risk for infection 2) Pain 3) Knowledge Deficit 4) Anticipatory Grieving
ANSWER: 2 - Pain For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority. Although the potential for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving, but this is not the priority at this time.
A client with severe pre-eclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client's plan of care? 1) Daily weights 2) Seizure precautions 3) Right lateral positioning 4) Stress reduction
ANSWER: 2 - Seizure precautions Women hospitalized with severe pre-eclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Because of edema, daily weight is important but not the priority. Pre-eclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.
The nurse documents positive ballottement in the client's prenatal record. The nurse understands that this indicates which of the following? 1) Palpable contractions of the abdomen 2) The fetus is not engaged in the pelvis 3) Fetal kicking felt by the client 4) Enlargement and softening of the uterus
ANSWER: 2 - The fetus is not engaged in the pelvis Ballottement indicates passive movement of the unengaged fetus. This can be done with a vaginal exam where the examiner can push up on the fetus and the fetus "floats away" and is not well applied/engaged in the pelvis. Rupturing membranes when the fetus is not engaged increases the changes of a cord prolapse. Ballottement is not a contraction. Fetal kicking felt by the client represents quickening. Enlargement and softening of the uterus is known as Piskacek's sign.
The lab work for a new antepartal client shows a hemoglobin level of 13 g/dl. The client is concerned that she is anemic. The nurse should base her answer on the following: 1) A hemoglobin level of 13 g/dl is below normal and it may be a sign of iron deficiency anemia. 2) A hemoglobin level of 13 g/dl is above the normal level and is reassuring. 3) Even though a hemoglobin level of 13 g/dl is low for an adult, it is within normal limits for the first trimester of a pregnancy. 4) Even though a hemoglobin level of 13 g/dl is high for an adult, it is within normal limits for the first trimester of a pregnancy.
ANSWER: 3 - Even though a hemoglobin level of 13 g/dl is low for an adult, it is within normal limits for the first trimester of a pregnancy. During the first trimester of pregnancy the hemoglobin level below 11 g/dl is necessary for a diagnosis of iron deficiency anemia. The normal hemoglobin level is lower during pregnancy due to the greatly expanded plasma volume.
A pregnant client has a history of a severe mid-pelvic injury requiring surgery with pins due to a motor vehicle accident. The nurse is aware that this could prevent a fetus from passing through which structure during childbirth? 1) Symphysis pubis 2) Sacral promontory 3) Ischial spines 4) Pubic arch
ANSWER: 3 - Ischial spines The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis.
A gravid woman, who is 42 weeks' gestation, has just had a 20-min non-stress test (NST). Which of the following results would the nurse interpret as a reactive test? 1) Moderate fetal heart baseline variability 2) Maternal heart rate accelerations to 140 bpm lasting at least 20 seconds 3) Two fetal heart accelerations of 15 bpm lasting at least 15 seconds 4) Absence of maternal premature ventricular contractions
ANSWER: 3 - Two fetal heart accelerations of 15 bpm lasting at least 15 seconds This is the definition of a reactive non-stress test - there are 2 fetal heart accelerations of 15 bpm lasting 15 or more seconds during a 20 minute period and a baseline WNL.
A pregnant client expresses concern about her gestational diabetes and asks the nurse, "Does this mean I will be diabetic for the rest of my life?" Which is the most appropriate response by the nurse? 1) "In most cases, a woman with gestational diabetes will become a diabetic who is insulin-dependent" 2) "If you follow your diabetic diet, you will probably not have anything to worry about." 3) "As long as you don't become pregnant again you will not become a diabetic." 4) "There is a possibility that you may develop type 2 diabetes at some point in the future."
ANSWER: 4 - "There is a possibility that you may develop type 2 diabetes at some point in the future." There is about a 75% chance that a woman with gestational diabetes will develop type 2 diabetes in the future. 1 is incorrect because, in most cases, a woman with gestational diabetes will not become a diabetic who is insulin dependent. 2 is incorrect because, even with following a diabetic diet, there is still a high chance of developing type 2 diabetes. 3 is incorrect because, even if there are no subsequent pregnancies, there is still a high chance of developing type 2 diabetes.
What is the hormonal stimulation that differentiates the embryo as female? 1) Increase in maternal estrogen secretion 2) Decrease in maternal androgen secretion 3) Secretion of androgen by the fetal gonad 4) Secretion of estrogen by the fetal gonad
ANSWER: 4 - Secretion of estrogen by the fetal gonad The fetal gonad must secrete estrogen for the embryo to differentiate as a female. An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. Secretion of androgen by the fetal gonad would produce a male fetus.
The nurse is aware that the following would be an indication of placental detachment? (select all that apply) a. An abrupt lengthening of the cord b. An increase in the number of contractions c. Relaxation of the uterus d. Increased vaginal bleeding
a. An abrupt lengthening of the cord b. An increase in the number of contractions d. Increased vaginal bleeding Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? a)Three contractions occurring within a 10-minute period b)A fetal heart rate of 90 beats per minute c)Adequate resting tone of the uterus palpated between contractions d)Increased urinary output
b) A fetal heart rate of 90 beats per minute A normal fetal heart rate is 120-160 bpm. Bradycardia or late decelerations indicate fetal distress and the need to discontinue the Pitocin. The goal of labor augmentation is to achieve 3 good quality contractions in a 10-minute period.
The nurse is aware that labor is divided into how many stages? a. Five b. Three c. Two d. Four
D) Four Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, recovery. The first stage is divided into three phases: early, active, and transition.
When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation? 1) Two ova fertilized by separate sperm 2) Sharing of a common placenta 3) Each ova with the same genotype 4) Sharing of a common chorion
ANSWER: 1 - two ova fertilized by separate sperm Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozygotic (identical) twins involve a common placenta, same genotype, and common chorion.
During pregnancy, the cardiac output is highest when the woman is in which position? 1) Side lying2) Sitting3) Standing4) Supine
ANSWER: 1- Side lying Cardiac output is highest when the woman is lying on her side and lower in the sitting, standing, or supine position.
During the initial assessment of a patient who is in her 3rd month of pregnancy, the nurse discovers that the client has to stand up for 8 hours at work. The nurse is aware that this may increase the client's risk of: 1) ankle edema. 2) blood clots. 3) preterm labor. 4) vaginal bleeding.
ANSWER: 2 - Blood clots. During pregnancy the plasma fibrinogen rises about 50% and plasma fibrin increases about 40%. These increase the risk of blood clots. The fact that the client stands for prolonged periods increases stasis of blood in the veins of the legs, which further increases the risk for blood clots.
FHM: VEAL CHOP
V - variable E - early decels A - accels L - late decels C - cord compression H - head compression O - OK P - Placental insufficiency
