Exam 2

A nurse palpates a woman's fundus to determine contraction intensity. What would be most appropriate for the nurse to use for palpation? A. finger pads B. palm of the hand C. finger tips D. back of the hand

Answer: A

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. boggy, soft uterus B. uterus becoming discoid shaped C. sudden gush of dark blood from the vagina D. shortening of the umbilical cord

Answer: C Rationale: Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.

A nurse is caring for several women in labor. The nurse determines that which woman is the latent phase of labor? A. contractions every 5 minutes, cervical dilation 3 cm B. contractions every 3 minutes, cervical dilation 6 cm C. contractions every 2 1/2 minutes, cervical dilation 8 cm D. contractions every 1 minute, cervical dilation 9 cm

ANS A Rationale: Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent phase. Contractions every 3 minutes with cervical dilation of 6 cm, contractions every 2½ minutes with cervical dilation of 8 cm, and contractions every 1 minute with cervical dilation of 9 cm suggest the active phase of labor.

A nurse is conducting a presentation for a group of pregnant women about measures to prevent toxoplasmosis. The nurse determines that additional teaching is needed when the group identifies which measure as preventive? A. washing raw fruits and vegetables before eating them B. cooking all meat to an internal temperature of 125° F (52° C) C. wearing gardening gloves when working in the soil D. avoiding contact with a cat's litter box

ANS B Rationale: Meats should be cooked to an internal temperature of 160° F (71° C). Other measures to prevent toxoplasmosis include peeling or thoroughly washing all raw fruits and vegetables before eating them, wearing gardening gloves when in contact with outdoor soil, and avoiding the emptying or cleaning of a cat's litter box.

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted? A. platypelloid B. gynecoid C. android D. anthropoid

ANS B Rationale: The most favorable pelvic shape for vaginal birth is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth, but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth

The nurse reviews the medical record of a woman who has come to the clinic for an evaluation. The client has a history of mitral valve prolapse and is listed as risk class II. During the visit, the woman states, "We want to have a baby, but I know I am at higher risk. But what is my risk, really?" Which response by the nurse would be appropriate? A. "If you do get pregnant, you will need to be seen by a cardiologist every other month for monitoring." B. "Your risk during pregnancy is small, but you should see your cardiologist first before getting pregnant." C. "Your heart disease would put too much strain on your heart if you were to get pregnant." D. "Your pregnancy would be uneventful, but you would need specialized care for labor and birth."

ANS B Rationale: Typically, a woman with class I or II cardiac disease can go through a pregnancy without major complications. For class I disease, there is no detectable increased risk of maternal mortality and no increase or a mild increase in morbidity. For class II disease, there is a small increased risk of maternal mortality or moderate increase in morbidity and cardiac consultation should occur every trimester. It is best to have the woman see her cardiologist before becoming pregnant. A woman with class III disease needs frequent visits with the car diac care team throughout pregnancy. There is a significantly increased risk of maternal mortality or severe morbidity and cardiologist consult should occur every other month with prenatal care and delivery occurring at an appropriate level hospital. A woman with class IV disease is typically advised to avoid pregnancy.

After teaching a group of nurses working at the women's health clinic about the impact of pregnancy on the older woman, which statement by the group indicates that the teaching was successful? A. "The majority of women who become pregnant over age 35 experience complications." B. "Women over the age of 35 who become pregnant require a specialized type of assessment." C. "Women over age 35 and are pregnant have an increased risk for spontaneous abortions." D. "Women over age 35 are more likely to have a substance use disorder."

ANS C

A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A. supine B. lithotomy C. upright D. knee-chest

ANS C Rationale: The use of any upright position helps to reduce the length of labor. Research shows that women who assumed the upright position during the first stage of labor experienced significant improvement in the progress of labor, faster fetal head descent, significant reduction of pain, and a good Apgar score.

A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching? A. "I should take my iron with milk." B. "I should avoid drinking orange juice." C. "I need to eat foods high in fiber." D. "I'll call the primary care provider if my stool is black and tarry."

ANS C Rationale: Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her primary care provider.

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome? A. congenital anomalies B. incompetent cervix C. placenta previa D. placental abruption (abruptio placentae)

Answer: A Rationale: A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or placental abruption (abruptio placentae).

A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect? A. uterine hyperstimulation B. headache C. blurred vision D. hypotension

Answer: A Rationale: A major adverse effect of the obstetric use of misoprostol is hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Headache, blurred vision, and hypotension are associated with magnesium sulfate.

A nurse is conducting a review class for a group of perinatal nurses working at the local clinic. The clinic sees a high population of women who are HIV positive. After discussing the recommendations for antiretroviral therapy with the group, the nurse determines that the teaching was successful when the group identifies which rationale as the underlying principle f or the therapy? A. reduction in viral loads in the blood B. treatment of opportunistic infections C. adjunct therapy to radiation and chemotherapy D. can cure acute HIV/AIDS infections

Answer: A Rationale: Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS.

Which action is a priority when caring for a woman during the fourth stage of labor? A. assessing the uterine fundus B. offering fluids as indicated C. encouraging the woman to void D. assisting with perineal care

Answer: A Rationale: During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase? A. increment B. acme C. peak D. decrement

Answer: A Rationale: Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.

When planning the care of a woman in the latent phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? A. every 30 to 60 minutes B. every 60 to 90 minutes C. every 15 to 30 minutes D. every 10 to 15 minutes

Answer: A Rationale: FHR is assessed every 30 to 60 minutes during the latent phase of labor and every 15 to 30 minutes during the active phase. The woman's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after ruptured membranes. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active and transition phases. Contractions are assessed every 30 to 60 minutes the latent phase and every 15 to 30 minutes during the active phase, and every 15 minutes during transition.

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A. frank B. full C. complete D. footling

Answer: A Rationale: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A. "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B. "Since this is your first pregnancy, you can estimate it will be about 10 hours." C. "It will depend on how big the baby is when you go into labor." D. "Time isn't important; your health and the baby's health are key."

Answer: A Rationale: It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last. There is no way to estimate the likely strength and frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the complex fetal rotations needed for an efficient labor will take place properly. All of these factors are unknowns when a woman starts labor.

A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver? A. Fetal presentation B. Fetal position C. Fetal attitude D. Fetal flexion

Answer: A Rationale: Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. The first maneuver determines presentation; the second maneuver determines position; the third maneuver confirms presentation by feeling for the presenting part; the fourth maneuver determines attitude based on whether the fetal head is flexed and engaged in the pelvis.

A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique? A. "Inhale through your nose and exhale through pursed lips." B. "Inhale and exhale through your mouth about 4 times in 5 seconds." C. "Forcefully exhale every so often after inhaling and exhaling through your mouth." D. "Take a cleansing breath before but not after each contraction."

Answer: A Rationale: Many couples learn patterned-paced breathing during their childbirth education classes. Three levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction. In the first pattern, also known as slow-paced breathing, the woman inhales slowly through her nose and exhales through pursed lips.

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. uterus becomes globular B. fetal head at vaginal opening C. umbilical cord shortens D. mucous plug is expelled

Answer: A Rationale: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.

A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why." Which response by the nurse would be most appropriate? A. "You had a burst of epinephrine, which is common before labor." B. "You were trying to get everything ready for your baby." C. "You felt your mind telling you that you were about to go into labor." D. "You were looking forward to the birth of your baby."

Answer: A Rationale: Some women report a sudden increase in energy before labor. This is sometimes referred to as nesting because many women will focus this energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household. The increased energy level usually occurs 24 to 48 hours before the onset of labor.

When teaching a class of pregnant women about the effects of substance use during pregnancy, the nurse would include which effect? A. low-birthweight infants B. excessive weight gain C. higher pain tolerance D. longer gestational periods

Answer: A Rationale: Substance use during pregnancy is associated with low birth weight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance use.

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis? A. sutures B. fontanelles C. frontal bones D. biparietal diameter

Answer: A Rationale: Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones, along with the parietal and occipital bones are bones of the cranium that are soft and pli able. The biparietal diameter is an important diameter that can affect the birth process.

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth? A. 11 B. 7 C. 5 D. 3

Answer: A Rationale: The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Therefore the woman with a Bishop score of 11 would have the greatest chance for success. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.

A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include? A. implementing measures for a vaginal birth B. preparing the client for a cesarean birth C. assisting with artificial rupture of the membranes D. instituting continuous internal fetal monitoring

Answer: A Rationale: The fetal presentation and position is left occiput anterior position or LOA, which is the most common and most favorable fetal position for birth. LOA along with right occiput anterior position are optimal positions for vaginal birth. Therefore the nurse should implement measures for a vaginal birth.

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth? A. cesarean B. vaginal C. forceps-assisted D. vacuum extraction

Answer: A Rationale: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A. latent phase of the first stage. B. active phase of the first stage. C. pelvic phase of the second stage. D. early phase of the third stage.

Answer: A Rationale: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother. The third stage, placental expulsion, starts after the newborn is born and ends wi th the separation and birth of the placenta.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? A. Check the fetal heart rate. B. Perform a vaginal exam. C. Notify the primary care provider immediately. D. Change the linen saver pad.

Answer: A Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply. A. cervical dilation of 6 cm B. contractions every 2 to 3 minutes C. cervical effacement of 30% D. contractions every 90 seconds E. strong desire to push

Answer: A, B Rationale: During the active phase, the cervix usually dilates from 6 to 10 cm, with 40% to 100% effacement taking place. Contractions become more frequent, occurring every 2-5 min and increase in duration (45 to 60 seconds). Effacement of 30% reflects the latent phase. Contractions occurring every 90 seconds suggest the second stage of labor. A strong urge to push reflects the later perineal phase of the second stage of labor

A pregnant client has received dinoprostone. Following administration of this medication, the nurse assesses the client and determines that the client is experiencing an adverse effect of the medication based on which client report? Select all that apply. A. headache B. nausea C. diarrhea D. tachycardia E. hypotension

Answer: A, B, C Rationale: Adverse effects associated with dinoprostone include headache, nauseas and vomiting, and diarrhea. Tachycardia and hypotension are not associated with this drug.

After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which foods as being good sources of iron in her diet? Select all that apply. A. dried fruits B. peanut butter C. meats D. milk E. white bread

Answer: A, B, C Rationale: Foods high in iron include meats, green leafy vegetables, legumes, dried fruits, whole grains, peanut butter, bean dip, whole-wheat fortified breads, and cereals.

A nurse is taking a history on a woman who is at 20 weeks' gestation. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. dull low backache B. viscous vaginal discharge C. dysuria D. constipation E. occasional cramping

Answer: A, B, C Rationale: Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour. Occasional asymptomatic cramping can be normal.

A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she may be in labor. To determine if the client is experiencing labor, which question(s) would be appropriate for the nurse to ask? Select all that apply. A. "Are you feeling any pressure or heaviness in your pelvis?" B. "Are you having contractions that come and go, off and on?" C. "Have you noticed any fluid leaking from your vagina? D. "Are you having problems with heartburn?" E. "Have you been having any nausea or vomiting?"

Answer: A, B, C, E

A nurse is conducting an in-service program for a group of labor and birth unit nurses about cesarean birth. The group demonstrates understanding of the information when they identify which conditions as appropriate indications? Select all that apply. A. active genital herpes infection B. placenta previa C. previous cesarean birth D. prolonged labor E. fetal distress

Answer: A, B, C, E Rationale: The leading indications for cesarean birth are previous cesarean birth, breech presentation, dystocia, and fetal distress. Examples of specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or placental abruption), previous classic uterine incision or scar, gestational hypertension, diabetes, positive human immunodeficiency virus (HIV) status, and dystocia. Fetal indications include malpresentation (nonvertex presentation), congenit al anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress.

Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply. A. walking with partner support B. straddling with forward leaning over a chair C. closed knee-chest position D. rocking back and forth with foot on chair E. supine with legs raised at a 90-degree angle

Answer: A, B, D

A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply. A. nifedipine B. magnesium sulfate C. dinoprostone D. misoprostol E. indomethacin

Answer: A, B, E Rationale: Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and nifedipine (a calcium channel blocker). These drugs are used "off label": this means they are effective for this purpose but have not been officially tested and developed for this purpose by the FDA. Dinoprostone and misoprostol are used to ripen the cervix.

A nurse is conducting an in-service program for a group of nurses working in the labor and birth suite of the facility. After teaching the group about the factors affecting the labor process, the nurse determines that the teaching was successful when the group identifies which component as part of the true pelvis? Select all that apply. A. pelvic inlet B. cervix C. mid pelvis D. pelvic outlet E. vagina F. pelvic floor muscles

Answer: A, C, D Rationale: The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. When reporting this suspicion, which finding(s) would the nurse include in the report? Select all that apply. A. significant difficulty breathing B. hypertension C. tachycardia D. pulmonary edema E. bleeding with bruising

Answer: A, C, D, E Rationale: Anaphylactoid syndrome of pregnancy (ASP), also known as amniotic fluid embolism, is an unforeseeable, life-threatening complication of childbirth. The etiology of ASP remains an enigmatic, devastating obstetric condition associated with significant maternal and newborn morbidity and mortality. It is a rare and often fatal event characterized by the sudden onset of hypotension, cardiopulmonary collapse, hypoxia, and coagulopathy. ASP should be suspected in any pregnant women with an acute onset of dyspnea, hypotension, and DIC. By knowing how to intervene, the nurse can promote a better chance of survival for both the mother and her newborn.

A 32-year-old black woman in her second trimester has come to the clinic for an evaluation. While interviewing the client, she reports a history of fibroids and urinary tract infection. The client states, "I know smoking is bad and I have tried to stop, but it is impossible. I have cut down quite a bit though, and I do not drink alcohol." Complete blood count results reveal a low red blood cell count, low hemoglobin, and low hematocrit. When planning this client's care, which factor(s) would the nurse identify as increasing the client's risk for preterm labor? Select all that apply. A. African heritage B. Maternal age C. History of fibroids D. Cigarette smoking E. History of urinary tract infections F. Complete blood count results

Answer: A, C, D, E, F Rationale: For this client, risk factors associated with preterm labor and birth would include African heritage, cigarette smoking, uterine abnormalities, such as fibroids, urinary tract infection, and possible anemia based on her complete blood count results. Maternal age ext remes (younger than 16 years and older than 35 years) are also a risk factor but do not apply to this client.

A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include? Select all that apply. A. internal rotation B. abduction C. descent D. pronation E. flexion

Answer: A, C, E Rationale: The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.

A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply. A. presence of a support partner B. view of birth as a stressor C. low anxiety level D. fear of loss of control E. participation in a pregnancy exercise program

Answer: A, C, E Rationale: Numerous factors can affect a woman's coping ability during labor and birth. Having the presence and support of a valued partner during labor, engaging in exercise during pregnancy, viewing the birthing experience as a meaningful rather than stressful event, and a low anxiety level can promote a woman's ability to cope. Excessive anxiety may interfere with the labor progress, and fear of labor and loss of control may enhance pain perception, increasing the fear.

A nurse has been invited to speak at a local high school about adolescent pregnancy. When developing the presentation, the nurse would incorporate information related to which aspects? Select all that apply. A. peer pressure to become sexually active B. rise in teen birth rates over the years. C. Asian Americans as having the highest teen birth rate D. loss of self-esteem as a major impact E. about half occurring within a year of first sexual intercourse

Answer: A, D Rationale: Adolescent pregnancy has emerged as one of the most significant social problems facing our society. Early pregnancies among adolescents have major health consequences for mothers and their infants. The latest estimates show that approximately 1 million teenagers become pregnant each year in the United States, accounting for 13% of all U.S. births, but the rates have been declining in the last several years.

Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor? A. "Lying flat with your head elevated on two pillows makes pushing easier." B. "Choose whatever method you feel most comfortable with for pushing." C. "Let me help you decide when it is time to start pushing." D. "Bear down like you're having a bowel movement with every contraction."

Answer: B

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: A. normal. B. a possible infection. C. meconium passage. D. transient fetal hypoxia.

Answer: B Rationale: Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertensi on, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. respiratory rate of 16 breaths per minute B. 1+ deep tendon reflexes C. urine output of 45 mL/hour D. alert level of consciousness

Answer: B Rationale: Diminished deep tendon reflexes (1+) suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? A. extent of opening to its widest diameter B. degree of thinning C. passage of the mucous plug D. fetal presenting part

Answer: B Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? A. intact membranes B. cervical dilation of 2 cm or more C. floating presenting fetal part D. a neonatologist to insert the electrode

Answer: B Rationale: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which schedule would be most appropriate? A. monthly visits until 32 weeks, then bi-monthly visits B. bi-monthly visits until 28 weeks, then weekly visits C. monthly visits until 20 weeks, then bi-monthly visits D. bi-monthly visits until 36 weeks, then weekly visits

Answer: B Rationale: For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance.

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. syphilis B. gonorrhea C. chlamydia D. HPV

Answer: B Rationale: Infection with gonorrhea during pregnancy can cause ophthalmia neonatorum in the newborn from birth through an infected birth canal. Infection with syphilis can cause congenital syphilis in the neonate. Infection with chlamydia can lead to conjunctivitis or pneumonia in the newborn. Exposure to HPV during birth is associated with laryngeal papillomas.

A nurse is explaining to a group of nurses new to the labor and birth unit about methods used for cervical ripening. The group demonstrates understanding of the information when they identify which method as a mechanical one? A. herbal agents B. laminaria C. membrane stripping D. amniotomy

Answer: B Rationale: Laminaria is a hygroscopic dilator that is used as a mechanical method for cervical ripening. Herbal agents are a nonpharmacologic method. Membrane stripping and amniotomy are considered surgical methods.

A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event has most likely occurred? A. cervical dilation B. lightening C. bloody show D. Braxton Hicks contractions

Answer: B Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower b ack pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor.

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? A. increased energy level with alternating strong and weak contractions B. moderately strong contractions every 4 minutes, lasting about 1 minute C. contractions noted in the front of abdomen that stop when she walks D. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

Answer: B Rationale: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

The nurse is assessing a newborn of a woman who is suspected of abusing alcohol. Which newborn finding would provide additional evidence to support this suspicion? A. wide, large eyes B. thin upper lip C. protruding jaw D. elongated nose

Answer: B Rationale: Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities.

Which assessment finding will alert the nurse to be on the lookout for possible placenta l abruption during labor? A. macrosomia B. gestational hypertension C. gestational diabetes D. low parity

Answer: B Rationale: Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, intimate partner violence, and placental pathology. Macrosomia, gesta tional diabetes, and low parity are not considered risk factors.

A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group, the nurse determines that the teaching was successful based on which statement by the group? A. The bony pelvis plays a lesser role during labor than soft tissue. B. The pelvic outlet is associated with the true pelvis. C. The false pelvis lies below the imaginary linea terminalis. D. The false pelvis is the passageway through which the fetus travels.

Answer: B Rationale: The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? ' A. regular contractions B. cervical dilation (dilatation) C. fetal movement through the birth canal D. placental separation

Answer: B Rationale: The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage? A. Regular contractions B. Cervical dilation C. Fetal movement through the birth canal D. Placental separation

Answer: B Rationale: The primary change occurring during the first stage of labor is progressive cervical dilation. Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition? A. a low-lying placenta B. fetopelvic disproportion C. contraction ring D. uterine bleeding

Answer: B Rationale: The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.

A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes? A. stability of the woman's emotional and psychological status B. degree of blood glucose control achieved during the pregnancy C. reduction in retinopathy risk by frequent ophthalmologic evaluations D. control of blood urea nitrogen (BUN) levels for optimal kidney function

Answer: B Rationale: Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state.

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A. "Holding a pillow against my incision will help me when I cough." B. "I'm going to have to wait a few days before I can start breastfeeding." C. "I guess the nurses will be getting me up and out of bed rather quickly." D. "I'll probably have a tube in my bladder for about 24 hours or so."

Answer: B Rationale: Typically, breastfeeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and prom ote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.

A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? A. "Call us back when you start having contractions." B. "Come to the clinic or emergency department for an evaluation." C. "Drink 3 to 4 glasses of water and lie down." D. "Come in as soon as you feel the urge to push."

Answer: B Rationale: When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropria te because this occurs during the second stage of labor

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching? A. "This type of monitoring is the most accurate method for our baby." B. "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C. "This type of monitoring can only be used after my membranes rupture." D. "You'll be inserting a special electrode into my baby's scalp."

Answer: B Rationale: With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which action would the nurse expect to include when developing a plan of care for this woman? Select all that apply. A. administrating of penicillin G at the onset of labor B. avoiding scalp electrodes for fetal monitoring C. refraining from obtaining fetal scalp blood for pH testing D. administering antiretroviral therapy at the onset of labor E. electing for the use of forceps-assisted birth

Answer: B, C, D

A pregnant woman with chronic hypertension is entering her second trimester. The nurse is providing anticipatory guidance to the woman about measures to promote a healthy outcome. The nurse determines that the teaching was successful based on which client statement(s)? Select all that apply. A. "I will need to schedule follow-up appointments every 2 weeks until I reach 32 weeks' gestation." B. "I should try to lie down and rest on my left side for about an hour each day." C. "I will start doing daily counts of my baby's activity at about 24 weeks' gestation." D. "I will need to have an ultrasound at each visit beginning at 28 weeks' gestation." E. "I should take my blood pressure frequently at home and report any high readings."

Answer: B, C, E Rationale: The woman with chronic hypertension will be seen more frequently (every 2 weeks until 28 weeks' gestation and then weekly until birth) to monitor her blood pressure and to assess for any signs of preeclampsia. At approximately 24 weeks' gestation, the woman will be instructed to document fetal movement. At this same time, serial ultrasounds will be prescribed to monitor fetal growth and amniotic fluid volume. The woman should also have daily periods of rest (1 hour) in the left lateral recumbent position to maximize placental perfusion and use home blood pressure monitoring devices frequently (daily checks would be preferred), reporting any elevations

A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is having contractions sporadically. Which instructions would be most appropriate for the nurse to give the woman? Select all that apply. A. "Walk around the house for the next half hour." B. "Drink two or three glasses of water." C. "Lie down on your back." D. "Try emptying your bladder." E. "Stop what you are doing and rest."

Answer: B, D, E Rationale: Appropriate instructions for the woman who may be experiencing preterm labor include having the client stop what she is doing and rest for an hour, empty her bladder, lie down on her left side, and drink two to three glasses of water

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A. intense B. strong C. moderate D. mild

Answer: C Rationale: A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong or intense contraction feels like the forehead.

A nurse is preparing a presentation for a group of young adult pregnant women about common infections and their effect on pregnancy. When describing the infections, which infection would the nurse include as the most common congenital and perinatal viral infection in the world? A. rubella B. hepatitis B C. cytomegalovirus D. parvovirus B19

Answer: C Rationale: Although rubella, hepatitis B, and parovirus B19 can affect pregnant women and their fetuses, cytomegalovirus (CMV) is the most common congenital and perinatal viral infection in the world. CMV is the leading cause of congenital infection, with morbidity and mortality at birth and sequelae. Each year approximately 1% to 7% of pregnant women acquire a primar y CMV infection. Of these, about 30% to 40% transmits infection to their fetuses.

A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which problem would the nurse likely include as the most common? A. macrosomia B. breech presentation C. persistent occiput posterior position D. multifetal pregnancy

Answer: C Rationale: Common problems involving the passenger include occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to cephalopelvic disproportion (CPD), and structural anomalies. Of these, persistent occiput posterior is the most common malposition, occurring in about 15% of laboring women

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A. "I'm feeling contractions mostly in my back." B. "My contractions are about 6 minutes apart and regular." C. "The contractions slow down when I walk around." D. "If I try to talk to my partner during a contraction, I can't."

Answer: C Rationale: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A. -2 B. -1 C. 0 D. +1

Answer: C Rationale: Fetal engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.

A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use? A. flexion B. extension C. longitudinal D. cephalic

Answer: C Rationale: Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are three primary lies: longitudinal, oblique, and transverse. Flexion and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal presentation.

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A. sedatives B. tocolytics C. uterine stimulants D. corticosteroids

Answer: C Rationale: For hypotonic labor, a uterine stimulant such as oxytocin may be prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A. "I'll basically follow the same diet that I was following before I became pregnant." B. "Because I need extra protein, I'll have to increase my intake of milk and meat." C. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D. "I'll adjust my diet and insulin based on the results of my urine tests for glucose."

Answer: C Rationale: In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.

A client has not received any medication during her labor. She is having frequent contractions about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A. latent phase of the first stage of labor. B. perineal phase of the first stage of labor. C. late active phase of the first stage of labor. D. early phase of the third stage of labor.

Answer: C Rationale: Late in the active phase of labor, contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies (moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in the serious work of her labor. She limits interactions with those in the room. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of the second stage is the period of active pushing. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta

A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next? A. suctioning of the mouth and nose B. clamping of the umbilical cord C. checking for the cord around the neck D. drying of the newborn

Answer: C Rationale: Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery.

Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A. -2 B. -1 C. 0 D. +1

Answer: C Rationale: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations.

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds? A. At the level of the woman's umbilicus B. In the area above the woman's umbilicus C. In the woman's lower abdominal quadrant D. At the upper outer quadrant of the woman's abdomen

Answer: C Rationale: The fetal heart rate is heard most clearly at the fetal back. In a cephalic presentation, the fetal heart rate is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A. +2 station. B. 0 station. C. -2 station. D. crowning

Answer: C Rationale: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

A pregnant client with iron-deficiency anemia is prescribed an iron supplement. After teaching the woman about using the supplement, the nurse determines that more teaching is needed based on which client statement? A. "Taking the iron supplement with food will help with the side effects." B. "I will need to avoid coffee and tea when I take this supplement." C. "I will take the iron with milk instead of orange or grapefruit juice." D. "If I happen to miss a dose, I will take it as soon as I remember."

Answer: C Rationale: The pregnant client should take the iron supplement with vitamin C-containing fluids such as orange juice, which will promote absorption, rather than milk, which can inhibit iron absorption. Taking iron on an empty stomach improves its absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman is advised to take it with meals

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? A. occiput B. face C. buttocks D. shoulder

Answer: C Rationale: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation.

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR? A. over the uterine fundus where contractions are most intense B. above the umbilicus toward the right side of the diaphragm C. between the umbilicus and the symphysis pubis D. between the xiphoid process and umbilicus

Answer: C Rationale: The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? A. asphyxia B. clavicular fracture C. cephalhematoma D. central nervous system injury

Answer: C Rationale: Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.

A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect? A. amniotic fluid embolism B. shoulder dystocia C. uterine rupture D. umbilical cord prolapse

Answer: C Rationale: Uterine rupture is associated with crack cocaine use disorder. Generally, the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus

A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor and the passage of the fetus through the birth canal. As part of the class, the nurse explains that specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse identify as being most important in affecting the birth process? Select all that apply. A. Occipitofrontal B. Occipitomental C. Suboccipitobregmatic D. Biparietal E. Diagonal conjugate

Answer: C, D Rationale: The diameter of the fetal skull is an important consideration during the labor and birth process. Fetal skull diameters are measured between the various landmarks of the skull. Diameters include occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal. The two most important diameters that can affect the birth process are the suboccipitobre gmatic (approximately 9.5 cm at term) and the biparietal (approximately 9.25 cm at term) diameters.

A nurse is reviewing the medical record of a pregnant client. The nurse suspects that the client may be at risk for dystocia based on which factors? Select all that apply. A. plan for pudendal block anesthetic use B. multiparity C. short maternal stature D. Body mass index 30.2 E. breech fetal presentation

Answer: C, D, E Rationale: Risk factors for dystocia may include maternal short stature, obesity, hydramnios, uterine abnormalities, fetal malpresentation, cephalopelvic disproportion, overstimulation with oxytocin, maternal exhaustion, ineffective pushing, excessive size fetus, poor maternal positioning in labor, and maternal anxiety and fear

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A. posterior position B. firm C. closed D. shortened

Answer: D Rationale: A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: A. yellow. B. olive green. C. pink. D. blue.

Answer: D Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.

Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A. marijuana B. alcohol C. heroin D. cocaine

Answer: D Rationale: Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant.

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate? A. "You'll probably have a cesarean birth to prevent exposing your newborn." B. "Antibodies cross the placenta and provide immunity to the newborn." C. "Wait until after the infant is born, and then something can be done." D. "Antiretroviral medications are available to help reduce the risk of transmission."

Answer: D Rationale: Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of birth should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Wai ting until after the infant is born may be too late.

A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction? A. heart rate increase from 76 bpm to 90 bpm B. blood pressure rise from 110/60 mm Hg to 120/74 C. white blood cell count of 12,000 cells/mm3 D. respiratory rate of 10 breaths/minute

Answer: D Rationale: During labor, the mother experiences various physiologic responses including an increase in heart rate by 10 to 20 bpm, a rise in blood pressure by up to 35 mm Hg during a contraction, an increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma, and an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism. A drop in respiratory rate would be a cause for concern.

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman makes which statement? A. "I'll sit down to rest for 30 minutes." B. "I'll try to move my bowels." C. "I'll lie down with my legs raised." D. "I'll drink several glasses of water."

Answer: D Rationale: If the woman experiences any signs and symptoms of preterm labor, she should stop what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three glasses of water, feel her abdomen and note the hardness of the contraction, and call her health care provider and describe the contraction.

A woman with a history of asthma comes to the clinic for evaluation for pregnancy. The woman's pregnancy test is positive. When reviewing the woman's medication therapy regimen for asthma, which medication would the nurse identify as problematic for the woman now that she is pregnant? A. ipratropium B. albuterol C. salmeterol D. Prednisone

Answer: D Rationale: Oral corticosteroids such as prednisone are not preferred for the long-term treatment of asthma during pregnancy. Inhaled steroids are the choice for maintenance medications to reduce inflammation that leads to bronchospasm. Common ones prescribed include beclomethasone and salmeterol. Rescue agents such as albuterol or ipratropium provide immediate symptomatic relief by reducing acute bronchospasm.

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention? A. fetal heart rate of 150 beats/minute B. contractions every 2 minutes, lasting 45 seconds C. uterine resting tone of 14 mm Hg D. urine output of 20 mL/hour

Answer: D Rationale: Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minute. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention.

A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at: A. 16 weeks' gestation. B. 28 weeks' gestation. C. 32 weeks' gestation. D. 36 weeks' gestation.

Answer: D Rationale: Pregnant women between 36 and 37 weeks' gestation should be universally screened for GBS infection during a prenatal visit and if positive, receive appropriate intrapartum antibiotic prophylaxis.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A. supine B. side-lying C. sitting D. knee-chest

Answer: D Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression

A pregnant woman asks the nurse, "I'm a big coffee drinker. Will the caffeine in my coffee hurt my baby?" Which response by the nurse would be most appropriate? A. "The caffeine in coffee has been linked to birth defects." B. "Caffeine has been shown to restrict growth in the fetus." C. "Caffeine is a stimulant and needs to be avoided completely." D. "If you keep your intake to less than 200 mg/day, you should be okay."

Answer: D Rationale: The effect of caffeine intake during pregnancy on fetal growth and development is still unclear. A recent study found that caffeine intake of no more than 200 mg/day during pregnancy does not affect pregnancy duration and the condition of the newborn. Birth defects have not been linked to caffeine consumption, but maternal coffee consumption decreases iron absorption and may increase the risk of anemia during pregnancy. It is not known if there is a correlation between high caffeine intake and miscarriage due to lack of sufficient studies.

A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse most likely use when explaining this measure? A. "This technique focuses on manipulating body tissues." B. "The technique requires focusing on a specific stimulus." C. "This technique redirects energy fields that lead to pain." D. "The technique involves light stroking of the abdomen with breathing."

Effleurage involves light stroking of the abdomen in rhythm with breathing. Therapeutic touch is an energy therapy and is based on the premise that the body contains energy fields that lead to either good or ill health and that the hands can be used to redirect the energy fields that lead to pain. Attention focusing and imagery involve focusing on a specific stimulus. Massage focuses on manipulating body tissues.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? A. Check the pH to ensure the fluid is amniotic fluid. B. Prepare to administer an antibiotic. C. Notify the health care provider about possible meconium. D. Check the maternal heart rate.

Rationale: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic t herapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which area? A. skin B. muscles of perineal body C. anal sphincter D. anterior rectal wall

Rationale: The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second-degree laceration extends through the muscles of the perineal body; a third-degree laceration continues through the anal sphincter muscle; and a fourth-degree laceration also involves the anterior rectal wall