LND and PP practice questions
Which assessments and interventions are needed once an epidural catheter has been inserted? SATA a. maintain IV fluid administration b. have oxygen available in case of hypotension c. check the bladder for distention every 2 hours d. position the client supine for ease of monitoring e. monitor FHR and labor progress per hospital protocol f. administer an oxytocin infusion to maintain the labor pattern
a, b, c, e
which would the nurse ask the PP client to do before assessing her uterine fundus? a. drink fluids b. empty her bladder c. perform the valsalva maneuver d. assume the semi-Fowler position
empty her bladder
A vaginal exam reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior position. The contractions are occurring every 3-4 minutes, are lasting 60 seconds, and are of moderate intensity. Which description is appropriate to use when reporting on the client's condition? a. early first stage of labor b. transition stage of labor c. beginning second stage of labor d. midway through first stage of labor
midway through first stage of labor
Which combination of maternal and infant blood type would be an indication for administration of Rho (D) immunoglobuin (RhoGAM) to the PP client? a. mother A+ and infant O+ b. mother O- and infant O+ c. mother AB- and infant B- d. mother B+ and infant B-
mother O- and infant O+
the practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which? a. early rooming-in b. taking-in behaviors c. taking-hold behaviors d. parent-child attachment
parent-child attachment
the nurse is assessing a PP client for signs of hemorrhage by evaluating the degree of perineal pad saturation. Which other parameter can the nurse use to estimate blood loss in a PP client? a. odor of lochia b. color of lochia c. presence of small clots on the pad d. time elapsed between pad changes
time elapsed between pad changes
the nurse is giving discharge instructions to a new mother. which discharge instruction would the nurse give the new mother to help prevent PP infection? a. "don't take tub baths for at least 6 weeks." b. "eat a balanced diet and get as much rest as possible." c. "douche with a dilute antiseptic solution twice a day and continue for a week." d. "tampons are better than sanitary napkins for inhibiting bacteria in the PP period."
"eat a balanced diet and get as much rest as possible."
where would the nurse expect the fundus to be located on the second PP day? a. at the level of umbilicus b. 1 fingerbreadth above umbilicus c. above and to the right of umbilicus d. 1-2 fingerbreadths below umbilicus
1-2 fingerbreadths below umbilicus
Which is the optimal nursing intervention to minimize perineal edema after an episiotomy? a. applying ice packs b. offering warm sit bath c. administering aspirin as needed d. elevating hips on a pillow
applying ice packs
A client in active labor is 100% effaced, dilated 3 cm, and at +1 station. Which stage of labor has this client reached? a. first b. latent c. second d. transitional
first stage
which client would the nurse expect to experience the most severe afterbirth pains? a. grand multipara b. breast-feeding primipara c. primipara with vaginal delivery d. woman with cesarean delivery at 43 weeks gestation
grand multipara
While caring for a client during labor, which would the nurse remember about the second stage of labor? a. it ends at the time of birth b. it ends as the placenta is expelled c. it begins with the transition phase of labor d. it begins with the onset of strong contractions
it ends at time of birth
the nurse admits a client to the birthing unit at 40 weeks gestation and determines that her contractions are 10 minutes apart and her cervix is dilation 2 cm. Which stage of labor is the client in? a. second stage b. latent first stage c. active first stage d. transition stage
latent first stage
A primipara about to be discharged with her newborn asks the nurse many questions regarding infant care. which phase of maternal adjustment does this behavior illustrate? a. let-down b. taking-in c. taking-hold d. early parenting
taking-hold
After 8 hours PP the nurse determines that a client's fundus is 3 cm above the umbilicus and displaced to the right. which statement is most significant in confirming the reason for the location of the uterus? a. "I've been so thirsty the past few hours." b. "I went to the bathroom, but I can't seem to urinate." c. "I've changed my pad once since I got to my room." d. "I've had a lot of contractions, especially while I was nursing."
"I went to the bathroom, but I can't seem to urinate."
the nurse instructs a pregnant woman in labor that she must avoid lying on her back. What is the primary reason for this instruction? a. the supine position can prolong the course of labor b. decreased placental perfusion is seen in the supine position c. this position can lead to transient episodes of hypertension d. lying on the back interferes with free movement of the coccyx
decreased placental perfusion is seen in the supine position
before discharge, which suggestion would the nurse give to a nonnursing mother to help limit breast engorgement? a. place raw cabbage leaves over the breasts b. stop drinking milk for 1 week c. take an analgesic every 4 hours d. apply warm compresses to the breasts
place raw cabbage
which information about lactogenesis would the nurse provide to a new mother? a. oxytocin stimulates milk production b. suckling stimulates the release of oxytocin c. estrogen stimulates the secretion of lactogenic hormones d. placental separation stimulates the release of progesterone
suckling stimulates the release of oxytocin
on the third PP day after a cesarean birth a client tells the nurse that her breasts feel warm, firm, and tender. The skin is shiny and taut. Which condition would the nurse suspect as the cause of the client's breast discomfort? a. oversupply of milk b. mastitis c. bilateral plugged ducts d. physiologic engorgement
physiologic engorgement
for which reason would the nurse encourage a client to void during the first stage of labor? a. a full bladder is often injured during labor b. a full bladder may inhibit the progress of labor c. a full bladder jeopardizes the status of the fetus d. a full bladder predisposes the client to urinary infection
a full bladder may inhibit the progress of labor
on the third PP day after an unexpected cesarean birth, the nurse finds the client crying. the client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" Which information would the nurse consider when responding? a. the client's feelings will pass after she has bonded with her infant b. the client is probably suffering from PP depression and needs special care c. a cesarean birth may be a traumatic experience, but most woman know that it is a possible outcome d. a woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this
a woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this
A client's cervix is dilated 3 cm and 50% effaced. Her membranes have rupture; the amniotic fluid is clear, and the FHR is stable. Which outcome would the nurse anticipate? a. a prolonged second stage of labor b. a difficult birth resulting from delayed effacement c. birth of the fetus within a day d. the stimulation of labor with an oxytocin infusion
birth of the fetus within a day
the nurse is teaching a childbirth preparation class regarding the discomforts of labor. which condition has the greatest influence on the perception of pain for a woman in labor? a. parity of the client b. duration of the labor c. tension of the client d. difficulty of the labor
tension of the client
Which information would tell the nurse if a woman at 40 weeks gestation having contractions is in true labor? a. the cervix dilates and becomes effaced in true labor b. bloody show is the first sign of true labor c. the membranes rupture at the beginning of true labor d. fetal movements lessen and become weaker in true labor
the cervix dilates and becomes effaced in true labor
which information would the nurse include in the discharge teaching of a PP client? a. the prenatal Kegel tightening exercises should be continued b. a bowel movement may not occur for up to a week after the birth c. the episiotomy sutures will be removed at the first PP visit d. a PP checkup should be scheduled as soon as menses return
the prenatal Kegel tightening exercises should be continued