Maternal Exam 2

A nurse is reinforcing teaching with a group of adolescent females who are pregnant about expected changes related to pregnancy. Which of the following client statements indicates understanding of the teaching? A. "It is normal to have a white vaginal discharge." B. "I should recognize fetal movement by 12 weeks." C. "I will take fluid pills if my ankles begin to swell." D. "My nipples and areolae will become pale as my breasts enlarge."

"It is normal to have a white vaginal discharge." Hormone stimulation causes leukorrhea, in which the cervix produces excess mucous. The nurse should instruct the client to use good perineal hygiene and report any discharge that is foul-smelling or a different color.

A nurse is caring for a client who is receiving magnesium sulfate to treat severe preeclampsia and asks the nurse "Is the medication working?" Which of the following responses should the nurse make? A. "The medication is working because there are no contractions." B. "The medication is working, because there is no seizure activity." C. "The medication is working, because all your lung fields are clear." D. "The medication is working, because your blood pressure is normal."

"The medication is working, because there is no seizure activity." Magnesium sulfate can be used for various reasons, including antacid, antiarrhythmic, anticonvulsant, electrolyte replacement and laxative. The primary indication for the client who is being treated for preeclampsia is the anticonvulsant properties. It is the preferred drug to prevent seizures in preeclampsia and treat seizures associated with eclampsia.

1.A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? A. "There is an increased risk of introducing infection." B. "This could initiate preterm labor." C. "This could result in profound bleeding." D. "There is an increased risk of rupture of the membranes."

"This could result in profound bleeding." "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? A. Assess deep tendon reflexes every hour. B. Obtain a daily weight. C. Continuous fetal monitoring D. Ambulate twice daily.

Ambulate twice daily A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, non-stimulating environment to prevent seizures and promote optimal placental blood flow

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? A. Monitor vaginal bleeding B. Administer glucocorticoids. C. Insert an IV catheter. D. Apply an external fetal monitor.

Apply an external fetal monitor. Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take? A. Cut the umbilical cord. B. Apply perineal pressure to the emerging fetal head. C. Prevent the perineum from tearing. D. Promote delivery of the placenta.

Apply perineal pressure to the emerging fetal head. Using Maslow's hierarchy of needs, the priority intervention is to prevent injury to the fetus during the delivery by applying gentle perineal pressure to the emerging head. This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull due to a rapid delivery can cause neurologic damage (increased intracranial pressure and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations.

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

Assess maternal pulse while listening to the fetal heart rate Because the medication should increase both the mother's pulse and term-25fetal heart rates, it is likely that the fetal monitor is mistakenly registering the maternal pulse rather than the fetal heart rate. If the pulsations are the same when the pulse of the mother and the fetal heart are monitored simultaneously, the nurse can determine that the mother's pulse rate is being monitored. It is not necessary to notify the doctor, stop the medication, or administer oxygen at this time.

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula. B. Assist the client to breathe into a paper bag C. Have the client tuck her chin to her chest D. Instruct the client to increase her respiratory rate to more than 42 breaths per min

Assist the client to breathe into a paper bag This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? A. Prepare for a cesarean birth. B. Assist the client to an upright position. C. Prepare for an immediate vaginal delivery. D. Assist the client to turn onto her side.

Assist the client to turn onto her side Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? A. The client reports weakness of the lower extremities. B. Blood pressure 80/56 mm Hg C. Temperature 38.2°C (100.8°F) D. The client reports perfuse itching.

Blood pressure 80/56 mm Hg When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? A. Limit alcohol consumption. B. Increase intake of iron-rich foods. C. Consume foods fortified with folic acid D. Avoid foods containing aspartame.

Consume foods fortified with folic acid Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? A. Expulsion of a blood-tinged mucous plug B. Continuous contraction lasting 2 min C. Pressure on the perineum causing the client to bear down D. Expulsion of clear fluid from the vagina

Continuous contraction lasting 2 min A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? a. Contractions lasting 60 seconds followed by a 1-minute rest period b. Contractions lasting 120 seconds followed by a 2-minute rest period c. Contractions lasting 2 minutes followed by a 60-second rest period d. Contractions lasting 1 minute followed by a 120-second rest period

Contractions lasting 1 minute followed by a 120-second rest period If the duration of a client is 60 seconds, that means it lasts 1 minute. The duration is from the beginning of the contraction to the end of the same contraction. Frequency is the beginning of a contraction to the beginning of the next contraction. If the contraction pattern has a frequency of 3 minutes, that means the start of one contraction to the start of the next is 3 minutes, or 180 seconds. If the duration of the contractions are 60 seconds, that leaves 120 seconds resting between each contraction

.A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? A. Contractions lasting longer than 90 seconds B. Contractions occurring every 3 to 5 min C. Contractions are strong in intensity D. Client reports feeling contractions in lower back

Contractions lasting longer than 90 seconds A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? A. 1+ pitting sacral edema B. 3+ protein in the urine C. Blood pressure 148/98 mm Hg D. Deep tendon reflexes of +1

Deep tendon reflexes of +1 Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex

On examination, it is noted that a full-term primipara in active labor is right occipitoanterior (ROA), 7cm dilated, 100% effaced, and +2 station. Which of the following should the nurse report to the physician? a. Fetal head is not yet engaged b. External rotation is complete c. Vaginal delivery is imminent d. Descent is progressing well

Descent is progressing well A +2 fetal station means the fetus is making positive progress moving down through the birth canal. The fetal head is considered "engaged" when it is at 0 station. Vaginal delivery is not imminent (meaning, about to happen) if this client is only 7 cm dilated for a patient that is a first time mother. The client must first dilate to 10cm prior to being able to start the 2nd stage of labor, which is when the patient can begin to push. The "external rotation" does not happen until the fetal head is delivered during the 2nd stage of labor.

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? A. Discontinue the medication infusion. B. Prepare for an emergency cesarean birth. C. Assess maternal blood glucose. D. Place the client in Trendelenburg position.

Discontinue the medication infusion. Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV.

A client who is 32 weeks pregnant is being monitored on the antepartum unit for severe preeclampsia. She suddenly complains of severe, continuous abdominal pain and vaginal bleeding. Which nursing interventions should be included in the care of this client? (Select all that apply) A. Evaluate maternal vital signs. B. Prepare for vaginal delivery. C. Reassure the client that she will be able to continue the pregnancy. D. Evaluate the fetal heart tones. E. Monitor the amount of vaginal bleeding. F. Monitor intake and output.

Evaluate maternal vital signs, Evaluate the fetal heart tones, Monitor the amount of vaginal bleeding, Monitor intake and output. The client's symptoms indicate that she is experiencing abruptio placentae. The nurse must evaluate maternal and fetal well-being. After the severity of the abruption has been determined and blood and fluid have been replaced, prompt cesarean delivery of the fetus (not vaginal) is indicated if the fetus is in distress. The nurse should not give false reassurance

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? A. Leukorrhea B. Urinary frequency C. Nausea and vomiting D. Facial edema

Facial edema Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider.

Secondary powers have a significant impact on cervical changes during labor a. True b. False

False Primary powers are the powers of the uterine contractions. They have significant impact on cervical effacement and dilation. The secondary powers are maternal pushing efforts (bearing down). These efforts are only applied to the labor process once the cervix has reached full dilation (10cm) and effacement (100%). The secondary powers assist the primary powers with expulsion of the fetus from the vaginal canal

A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? a. Maternal heart rate 60 bpm b. Beat-to-beat variability c. Early decelerations d. Fetal heart rate 190 bpm

Fetal heart rate 190 bpm Terbutaline, a beta agonist, stimulates the "fight or flight" response in the mother and in the fetus. The fetal heart rate, therefore, increases in response to the medication. The maternal heart rate increases with terbutaline instead of being low. Early decelerations are nonpathological, and are not related to terbutaline administration. Beat-to-beat variability is a positive sign and demonstrates fetal well-being.

A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include? A. Breast tenderness B. Fatigue C. Fetal heart tones detected by ultrasound D. Positive urine pregnancy test

Fetal heart tones detected by ultrasound Fetal heart tones are a positive sign of pregnancy because the presence of fetal heart tones can only be explained by pregnancy.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? A. Cephalic B. Transverse C. Posterior D. Frank breech

Frank breech With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus

A woman provides the nurse with the following obstetrical history: Delivered a son, now 7 years old, at 28 weeks' gestation; delivered a daughter, now 5 years old, at 39 weeks' gestation; had a miscarriage 3 years ago, and had a first-trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman's obstetrical history? a. G5P1122 b. G5P2211 c. G4P1212 d. G4P2121

G5P1122 G = 28 week pregnancy; 39 week pregnancy, miscarriage/abortion x2; currently pregnant = 5 T = (Term 37-42 weeks' gestation) 39 week gestation = 1 P = (Preterm 20-36 +6 weeks' gestation) 28 week gestation = 1 A = (Abortions/miscarriages from conception to 19 +6 weeks gestation) = 2 L = (Living children) = 7yr old son and 5yr old daughter = 2

A 37-year-old client at 34 weeks' gestation goes to the clinic for a routine visit. The client's height is 58" and her weight is 213lb. Her pre-pregnancy weight was 160lb. She tells the nurse that her last child weighed 9lb, 9oz. Based on this information, the client may have which of the following? a. Polycythemia. b. Oligohydramnios. c. Renal disease. d. Gestational diabetes.

Gestational diabetes. A client who is age 37 and obese and who has a history of large-birth weight infants is at risk for GDM.

A pregnant client at 32 weeks gestation has mild preeclampsia. She is discharged home with instructions to remain on bedrest. She should also be instructed to call her physician if she experiences which symptoms? (Select all that apply) a.Headache. b.Increased urine output. c.Blurred vision. d.Difficulty sleeping. e.Epigastric pain. f.Severe nausea and vomiting.

Headache, Blurred vision, Epigastric pain, Severe nausea and vomiting. Headache, blurred vision, epigastric pain, and severe N/V can indicate worsening maternal disease.

5.A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? A. Cocaine use B. Hypertension C. Blunt force trauma D. Cigarette smoking

Hypertension Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? A. Vomiting B. Tachycardia C. Respiratory depression D. Hypotension

Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.

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

Inform the mother that the rate is normal A normal fetal heart rate is 120-160 beats per minute. A fetal heart rate in the 150s is a normal fetal heart rate. There is no need to reassess the rate in 5 minutes as the rate is normal. The fetal heart rates that must be reported immediately to the health care provider are bradycardia and tachycardia. If the patient had bradycardia or tachycardia, then the patient should be placed on their left side and oxygen applied via face mask.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? A. Insert an indwelling urinary catheter. B. Initiate IV access C. Witness the signature for informed consent for surgery. D. Prepare the abdominal and perineal areas

Initiate IV access. Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.

A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply.) A. Eczema B. Psoriasis C. Linea nigra D. Chloasma E. Striae gravidarum

Linea nigra, Chloasma, Striae gravidarum :Eczema is incorrect. Eczema manifests as red, swollen, and itchy skin and is not an expected finding during pregnancy.Psoriasis is incorrect. Psoriasis manifests as thick red patches or plagues covered by silver scales on the skin and is not an expected finding during pregnancy.Linea nigra is correct. Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy.Chloasma is correct. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy.Striae gravidarum is correct. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy

0.A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? A. Fetal lung maturity B. Location of the placenta C. Viability of the fetus D. The biparietal diameter

Location of the placenta Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? A. Apply fundal pressure. B. Observe for the presence of a nuchal cord. C. Observe for crowning. D. Prepare to administer oxytocin.

Observe for crowning. In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

.A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? A. Have the client stand at the bedside with her arms at her side. B. Administer a 500 mL bolus of 5% dextrose in water prior to induction. C. Inform the client the anesthetic effect will last for approximately 6 hr. D. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction

Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? A. Place the client in the lateral position. B. Increase the rate of maintenance IV infusion. C. Elevate the client's legs. D. Administer oxygen using a nonrebreather mask.

Place the client in the lateral position. This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A woman has just been admitted to the emergency department subsequent to a head-on automobile accident. Her baby appears to be uninjured. The nurse carefully monitors the woman for which of the following complications of pregnancy? a. severe preeclampsia b. transverse fetal lie c. placental abruption d. placenta previa

Placenta abruption The fetus is well protected within the uterine body. The musculature of the uterus and the amniotic fluid provide the baby with enough cushioning to withstand minor bumps and falls. A major automobile accident, however, can cause anything from preterm premature rupture of the membranes, to a ruptured uterus, to placental abruption. The nurse should especially monitor the fetal heart beat for any variations.

A client who is 38 weeks' pregnant arrives at the hospital complaining of painless vaginal bleeding. She is documented at a G2, T1, P0, A0, and L1. The most likely cause of the bleeding is: a. Placenta previa. b. Ruptured uterus. c. Placenta accreta. d. Abruptio placenta

Placenta previa The classic sign of placenta previa is painless bleeding; the placenta partially or completely covers the cervical os and, therefore, as the cervix dilates the placenta separates and bleeds.

When caring for a prenatal client who has tested positive for the HIV virus, what post-delivery teaching would be a priority for this client? a. Breast-feeding to ensure the transfer of passive immunity. b. Encourage frequent holding of the infant to promote bonding. c. Plan to bottle-feed her infant with formula. d. Consume a high-protein diet after delivery to promote healing.

Plan to bottle-feed her infant with formula Breast-feeding isn't recommended for HIV-positive clients because HIV appears in breast milk and can be transmitted to the neonate through breast-feeding. Because breast-feeding isn't advisable, the HIV-positive client should prepare and use formula appropriately during bottle-feeding. The client should be given plenty of opportunity for bonding, and a high protein dies does promote healing, however, educating the client about the importance of bottle-feeding is priority at this time.

When caring for a prenatal client who has tested positive for the HIV virus, what post-delivery teaching would be a priority for this client? a. Encourage frequent holding of the infant to promote bonding. b. Consume a high-protein diet after delivery to promote healing. c. Breast-feeding to ensure the transfer of passive immunity. d. Plan to bottle-feed her infant with formula.

Plan to bottle-feed her infant with formula Breast-feeding isn't recommended for HIV-positive clients because HIV appears in breast milk and can be transmitted to the neonate through breast-feeding. Because breast-feeding isn't advisable, the HIV-positive client should prepare and use formula appropriately during bottle-feeding. The client should be given plenty of opportunity for bonding, and a high protein dies does promote healing, however, educating the client about the importance of bottle-feeding is priority at this time.

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? A. Elevate the client's legs. B. Position the client on her side. C. Administer oxygen via face mask. D. Increase the infusion rate of the IV fluid.

Position the client on her side. Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.

A patient is admitted to the emergency department at 37 weeks' gestation after a motor vehicle accident and is diagnosed with a fractured femur that will need surgical repair. What efforts on the part of the operating room team will best avoid risk to the fetus during the procedure? a. Use general anesthesia to avoid vasodilation. b. Hydrate the client with 5% dextrose in LR solution. c. Monitor the fetus with a scalp lead during the procedure. d. Position the patient on her left side and prop her with a wedge.

Position the patient on her left side and prop her with a wedge. Maternal hypotension causes the greatest risk to the fetus in maternal surgery during pregnancy. To avoid maternal hypotension, the mother should be placed on the operating room table tilted and propped on her left side to avoid vena caval compression.

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A. Left lower B. Right lower C. Left upper D. Right upper

Right Upper Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.

Which of the following situations is considered a vaginal delivery emergency? a. Shoulder dystocia b. Third stage of labor lasting 20 minutes c. Three vessel umbilical cord d. Fetal heart rate dropping during contractions

Shoulder dystocia Dystocia means difficult delivery. A shoulder dystocia, therefore, refers to difficulty in delivering a baby's shoulders. This is an obstetric emergency since the dystocia occurs in the middle of the delivery when the head has been delivered, but the shoulders remain wedged in the pelvis. The bay's life is threatened since the baby is unable to breathe and umbilical cord flow is often dramatically reduced during this phase of the delivery.

A woman, G4P0210 and 12 weeks gestation, has been admitted to the labor and delivery suite for a cerclage procedure. Which of the following long-term outcomes is appropriate for this client? a. The client will deliver after 37 weeks gestation b. The client will gain less than 25 pounds during the pregnancy. c. The client will delivery a baby that is apprpriate for gestational age. d. The client will have a normal blood glucose throughout the pregnancy

The client will deliver after 37 weeks gestation A cerclage is placed because of multiple pregnancy losses from cervical insufficiency (incompetent cervix). The gravity and parity information provides an important clue to the question. The client has had four pregnancies, with two preterm births and one abortion, but she has no living children. The goal for the therapy, therefore, is that the pregnancy will go to term.

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? a. The fetal presentation is vertex b. The fetal lie is vertical c. The fetal attitude is flexed d. The fetal position is transverse

The fetal lie is vertical The nurse palpates a hard, round mass in the fundal area of the uterus and must interpret that feeling as the fetal head. Similarly the nurse palpates a soft round mass above the symphysis and must interpret that feeling as the fetal buttocks. With these findings and interpretations, the nurse will then realize that the fetal lie is vertical. The attitude is difficult to determine when performing Leopold's maneuvers. Transverse is a lie, not a position. If the presentation was vertex, then the nurse would palpate the soft round mass in the fundal area, meaning the fetus was head down.

The nurse is monitoring a woman, G2P1001, 41 weeks' gestation, in labor. Based on the following assessments, what should the nurse conclude? A 12pm assessment revealed: cervix, 4cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5pm assessment: cervix, 6cm; 90% effaced; -3 station; and FH 120 with moderate variability. A 10pm assessment: cervix, 8cm; 100% effaced; -3 station; and FH 124 with moderate variability. a. The baby is in fetal distress b. Labor is progressing well c. The woman is likely carrying a macrosomic fetus d. The woman will be in second stage in about 5 minutes

The woman is likely carrying a macrosomic fetus Although dilation is progressing, the station is unchanged. The baby is not descending into the birth canal. The nurse cannot conclude that the labor is progressing well. Since the presenting part is not descending into the birth canal, the nurse can logically conclude that the baby is macrosomic. The fetal heart rate is virtually unchanged; the rate is within normal limits and the variability is normal. There is no sign of fetal distress. The dilation and effacement are changing, but the lack of progressive descent of the presenting part is unexpected. When babies are too big to fit through a client's pelvis, they fail to descend.

Nursing assessment during labor finds a fetal heart rate baseline of 135 prior to the onset of a contraction; a decrease to 110 during the contraction, and a return to baseline 40 seconds after the end of the contraction.

This is a late deceleration, which is always non-reassuring. Nursing interventions: aimed at increasing fetal oxygenation. If oxytocin is running, the infusion must be turned off. If the client is in a supine position, she should be repositioned to the left lateral position. If the client is hypotensive, increase the IV rate. Oxygen should be administered at 8-10 L/min. Continuous fetal monitoring is essential.

A woman at term pregnancy, gravida 5, para 4-0-0-4, has been examined by the nurse in the triage room of the labor and delivery unit. The nurse finds that the woman's contractions are 5 minutes apart, her cervix is 3 cm dilated and 10% effaced, station is 0, and membranes are intact. What should the nurse anticipate? a. The woman is at the beginning of active stage and will not deliver for at least 8 hours. b. At 3 cm with intact membranes, this woman is in latent labor and should return home. c. This woman is experiencing abnormal labor as evidenced by rapid contractions and progress in dilation without effacement. She should be observed carefully. d. This woman appears to be experiencing a normal active labor process for a multipara and should be admitted.

This woman appears to be experiencing a normal active labor process for a multipara and should be admitted Dilation without effacement is normal for a multipara, and regular contractions 5 minutes apart suggest the onset of active labor.

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? A. Variable decelerations are due to umbilical cord compression. B. Variable decelerations are caused by uteroplacental insufficiency C. Variable decelerations are a result of the administration of IV narcotic analgesics. D. Variable decelerations are related to fetal head compression.

Variable decelerations are due to umbilical cord compression. Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A. "This will occur during the last trimester of pregnancy." B. "This will happen by the end of the first trimester of pregnancy." C. "This will occur between the fourth and fifth months of pregnancy." D. "This will happen once the uterus begins to rise out of the pelvis."

"This will occur between the fourth and fifth months of pregnancy." Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks.

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727)

0504 ( July 4)

12.A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? A. 4-0-1-2-2 B. 3-0-2-0-2 C. 2-0-0-2-0 D. 4-2-0-2-2

4-0-1-2-2 This response correctly describes the client's current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L).

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta previa B. Prolapsed cord C. Incompetent cervix D. Abruptio placentae

Abruptio placentae The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions.

The nurse should anticipate that on the first postpartum day, the insulin requirements of a client with diabetes will: a. Rapidly increase. b. Remain unchanged. c. Decrease sharply and suddenly. d. Demonstrate a slow and steady decrease.

Decrease sharply and suddenly. Insulin requirements may fall suddenly during the first 24 to 48 hours postpartum because the endocrine changes of pregnancy are reversed. After placenta is delivered, tissues become sensitive again to insulin Lactation uses maternal glucose; so the breastfeeding mother's insulin requirements will remain low as long as she is nursing

If the fetal position is right occiput anterior (ROA), where should the nurse expect to find the fetal heart tones? a. In the right lower quadrant b. In the right upper quadrant c. In the left upper quadrant In the left lower quadrant

In the right lower quadrant The FHR is best heard through the fetal back; with a vertex presentation and with the fetal occiput to the mother's right, the fetal back is also on the mother's right and in the lower quadrant. To hear FHR best in the left upper quadrant, the fetus would need to be breech with the fetal back to the left side. To hear FHT best in the right upper quadrant, the fetus would need to be breech with the fetal back to the right side. To hear FHT best in the left lower quadrant, the fetus would need to be LOA.

The nurse administered Stadol to a patient in active labor and the patient's cervical dilation progressed faster than expected. What medication must the nurse have available and what potential complications can occur?

Narcan for neonatal respiratory depression

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. B. The client is immune to the rubella virus. C. The client requires a rubella vaccination at this time. D. The client requires a rubella immunization following delivery.

The client requires a rubella immunization following delivery. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.

The night shift nurse provides hand-off report to you at the beginning of your shift. In the report, the patients last exam was 5/75/+1 What does this mean?

The patient is: 5cm dilated 75% effaced +1 station

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? A. The presenting part is 1 cm above the ischial spines. B. The presenting part is 1 cm below the ischial spines. C. The cervix is 1 cm dilated. D. The cervix is effaced 1 cm

he presenting part is 1 cm above the ischial spines. Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? A. "I will reduce my stress level." B. "I will tell my doctor before using home remedies for nausea." C. "I will monitor my weight gain during the remaining months." D. "I will use only nonprescription medications while pregnant."

"I will use only nonprescription medications while pregnant." Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy.

A 30-year-old G2P0010 in preterm labor is receiving tocolytic therapy. Which of the following maternal assessments noted by the nurse must be reported to the health care practitioner immediately? a. Audible rales b. Heart rate of 100 bpm c. Wakefulness d. Daily output of 2000 cc

Audible rales The presence of audible rales is indicative of pulmonary edema, a serious side effect related to the class of medications.

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? A. Ballottement B. Lightening C. Quickening D. Chloasma

Quickening Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement.

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? A. Tachycardia B. Absence of clonus C. Polyuria D. Report of headache

Report of headache Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria

.A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? A. "Exercising during pregnancy is not recommended." B. "Daily jogging for up to 30 minutes is fine throughout the pregnancy." C. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." D. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."

"Daily jogging for up to 30 minutes is fine throughout the pregnancy." While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods.

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching? A. "I should limit my carbohydrates to 50% of caloric intake." B. "I will reduce my exercise schedule to 3 days a week." C. "I will take my glyburide daily with breakfast." D. "I know I am at increased risk to develop type 2 diabetes."

"I will reduce my exercise schedule to 3 days a week." Increased exercise benefits the client and can result in improved management of gestational diabetes.

4.A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? A. "This is a presumptive sign of pregnancy." B. "This is a probable sign of pregnancy." C. "This is a possible sign of pregnancy." D. "This is a positive sign of pregnancy."

"This is a presumptive sign of pregnancy." Presumptive signs of pregnancy include physical changes that are apparent to the client, such as quickening.

The charge nurse for the labor and delivery unit in a busy metropolitan hospital has four women present to the nursing station at the same time. Only one bed is available. Which client will have the priority for this bed? a. A 25 year old primigravida with bloody vaginal discharge at 16 weeks gestation. b. A 30 year old with decreased fetal movement at 38 weeks gestation. c. A 27 year old G2P1 at 40 weeks gestation to rule out labor. d. A 32 year old G3P2 with a documented intrauterine fetal demise.

A 30 year old with decreased fetal movement at 38 weeks gestation Answer 'a' is wrong because at 16 weeks a fetus is not considered viable. The woman should be admitted, but a high risk antepartum unit is the most appropriate placement. Answer 'c' is wrong because the woman the woman may not be in active labor. A triage/exam room is an appropriate placement. Answer 'd' is wrong because although the client who has had a fetal demise needs to be delivered within a few days of the demise, it is not an emergent situation and can wait for another bed to become available.

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first? a. A. A client who is at 38 weeks of gestation and reports a cough and fever B. A client who has missed a period and reports vaginal spotting C. A client who is at 14 weeks of gestation and reports nausea and vomiting D. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

A client who is at 28 weeks of gestation and reports of painless vaginal bleeding Using the urgent vs. nonurgent approach to client care, the nurse should assess this client first. The nurse should suspect placenta previa when vaginal bleeding occurs after 24 weeks of gestation. A pregnant woman can lose up to 40% of blood before showing signs of shock.

The nurse manager on a maternity unit is informed that a woman who is 36 weeks pregnant with severe preeclampsia is to be admitted to the unit. Which bed assignment is the best choice? a. Bed in a double room 50 feet from the nurse's station with a roommate who has rheumatic heart disease. b. Bed in a double room next to the nurse's station with a roommate who is withdrawing from drug addiction. c. Bed in a 4 bed unit with all postpartum women. d. Bed in a 4 bed unit with other women who have pyelonephritis, diabetes, and premature rupture of membranes.

Bed in a double room 50 feet from the nurse's station with a roommate who has rheumatic heart disease. The best choice is a quiet room close to the nurse's station to provide an opportunity for close observation and decreased stimulation. A private room is ideal, but not always an option and not one of the choices in this question. The other options offer too much noise, which can precipitate seizure activity.

A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse's first action should be to: a. Administer oxygen by face mask. b. Clear and maintain an open airway. c. Administer magnesium sulfate intravenously. d. Assess the blood pressure and fetal heart rate.

Clear and maintain an open airway

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? A. Apply a fetal scalp electrode. B. Increase the rate of the IV infusion. C. Administer oxygen at 10 L/min via a nonrebreather mask. D. Change the client's position. The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

Change the client's position. The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

.A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membrane B. Changes in the cervix C. Station of the presenting part D. Pattern of contractions

Changes in the cervix Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

At 37 weeks' gestation, a diabetic client delivers a neonate weighing 9lb 6oz. Which assessment is a priority for this neonate? a. Blood glucose levels. b. RBC count. c. Phenylketonuria (PKU) screen. Palmer grasp

Blood glucose levels A large-for-gestational-age neonate born to a diabetic mother needs immediate assessment of blood glucose levels to avoid developing hypoglycemia soon after birth. To prevent hypoglycemia, oral feedings or I.V. glucose infusions are started.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. Maintain the client in the lithotomy position. B. Perform vaginal examinations frequently. C. Remind the client to bear down with each contraction. D. Encourage the client to empty her bladder every 2 hr

Encourage the client to empty her bladder every 2 hr. A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? A. Assist the client into a comfortable position. B. Observe the perineum for signs of crowning. C. Have the client pant during the next contractions. D. Help the client to the bathroom to void.

Have the client pant during the next contractions. Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.

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

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

The nurse is reviewing fetal heart monitoring strips. The nurse understands that fetal tachycardia is most likely caused by: a. maternal hypotension b. compression of the fetal head c. compression of the umbilical cord d. maternal infection

Maternal infection A immediate cause of fetal tachycardia is a maternal infection. A compressed umbilical cord will cause a variable deceleration, or a decrease in the fetal heart rate. Compression of the fetal head causes early decelerations. Maternal hypotension causes fetal bradycardia.

A nurse is planning to administer butorphanol to a client who is in labor. Which of the following medications should the nurse plan to have available to reverse the action of this medication? A. Protamine B. Diphenhydramine C. Atropine D. Naloxone

Naloxone Butorphanol is an opioid analgesic. The nurse should have the opioid reversal agent naloxone and resuscitation equipment available in the event that the client develops respiratory depression.

A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis? a. Severe nausea and vomiting. b. Dark brown rectal bleeding. c. Sharp unilateral pain. d. Marked hyperthermia.

Sharp unilateral pain The most common location for an ectopic pregnancy to implant is in a fallopian tube. Because the tubes are nonelastic, when the pregnancy becomes too big, the tube ruptures. Unilateral pain can develop because only one tube is being affected by the condition. In addition, some women complain of generalized abdominal pain.

A patient's contractions have a frequency of every 2 to 3 minutes, and a duration of 90 seconds. A vaginal examination reveals that the client is 6 cm dilated, 100% effaced, and at +1 station. Based on this information, the nurse determines the patient is in what stage and phase of labor? a. Stage I, active phase b. Stage I, latent phase c. Stage I, transition phase d. Stage II, active phase

Stage I, active phase Stage 1 of labor includes the phases of latent, active and transition. Stage 1 begins with a closed cervix and ends when the cervix is 10cm dilated and 100% effaced. Stage 2 does not have any phases and includes pushing to delivery of the fetus. The phases of stage 1 are latent (beginning of labor, up to 4 cm dilated), early (5cm dilated to 7 cm), and transition (8cm to 10cm). The patient described in the question is reported to have regular contractions and is currently 6 cm dilated. This describes a patient who is in Stage 1 active labor.

The nurse in the prenatal clinic is interviewing a woman at 28 weeks' gestation. The woman complains of palpitations, feelings of smothering, difficulty breathing while doing common household tasks, and a persistent cough. The vital signs are: BP: 120/80 mmHg; P: 100 bpm; R: 28 per minute. The woman has edema in her fingers and ankles. The skin around her eyes is pale and puffy. What should the nurse determine? a. The woman has signs of cardiac decompensation and should see a physician immediately. b. The woman is experiencing normal discomforts of pregnancy. c. The woman is not physically fit and should start an exercise program. d. The woman should see a nutritionist to check her intake of sodium.

The woman has signs of cardiac decompensation and should see a physician immediately. The rapid pulse and respirations and dyspnea with normal activity plus periorbital edema may be early signs of a significant complication of pregnancy.

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? A. Two veins and one artery B. One artery and one vein C. Two arteries and one vein D. Two arteries and two veins

Two arteries and one vein The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta.

13.A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? A. Early decelerations B. Accelerations C. Late decelerations D. Variable decelerations

Variable decelerations Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus

A pregnant woman is discussing positioning and the use of leg stirrups for delivery with a labor nurse. In which of the following instances should the nurse provide further information to the client? a. When the client states, "I am glad that deliveries can take place in a variety of places, including a bathtub." b. When the client says, "During difficult deliveries, it is sometimes necessary to put a woman's legs up in stirrups." c. When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." d. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." Deliveries can be performed in a variety of positions, including lithotomy, squatting, and side-lying; in a variety of locations, including labor bed, delivery bed, shower, and in a dry environment or water. It is recommended that mothers consult with their health care practitioners early in the pregnancy regarding the practitioner's delivery practices, including birth positions. The mother's birth preference may influence her choice of caregiver.