Maternal Exam 3 10-12

The nurse is teaching a prenatal class. For which reason does the nurse emphasize the importance of managing maternal fear during labor? 1. Dystocia is associated with extreme fear. 2. Mothers cannot enjoy the actual birth. 3. Fear promotes feelings of exhaustion. 4. Fear during labor causes postpartum depression

1.Dystocia is associated with extreme fear. Extreme maternal fear or exhaustion can result in catecholamine release interfering with uterine contractility, a condition that will cause dystocia.

A patient in labor receives high-level regional anesthesia, which inhibits her ability to push during the second state of labor. The primary care provider (PCP) will use forceps to aid in the delivery of the fetus. Which fetal complications is the nurse aware of being related to a forceps birth? Select all that apply. 1. Intracranial hemorrhage 2. Skin lacerations 3. Nerve injuries 4. Cephalohematoma 5. Skull fracture

1,2,3,4,5 Intracranial hemorrhage is a possible complication of a forceps delivery and results from pressure on the fetal head by the forceps during birth. 2 Skin lacerations are a possible complication of forceps delivery and result primarily during the insertion of the forceps. 3 Nerve injuries are a possible complication of a forceps delivery and result from the pulling action of moving the fetus down the birth canal. 4 Cephalohematoma is a possible complication of a forceps delivery and results from pressure on the head, which causes the rupture of small blood vessels and the collection of blood beneath the scalp. 5 Skull fracture is a possible complication of a forceps delivery and results from pressure on the fetal skull during insertion of the forceps and/or when exerting pressure during extraction of the fetus.

The nurse is providing care for a patient who delivered via cesarean 24 hours ago. Which teaching does the nurse provide for the patient and family? Select all that apply. 1. Signs and symptoms to report to the health-care provider (HCP) 2. Comfortable positions for feeding the newborn 3. Encouragement for early dietary intake of solid foods 4. Encouragement for family to help with infant care and housework 5. Information on nutrition to promote tissue healing

1,2,3,4,5 The nurse teaches the patient and family about the signs and symptoms that need to be reported to the HCP. Patients with cesarean deliveries are more prone to infection. 2 Due to abdominal tenderness related to cesarean birth, the nurse will need to teach the mother and family about comfortable positions for feeding the newborn. Breastfeeding mothers may be more comfortable in a side-lying position. 3 . Following a cesarean, patients who eat solid foods early rather than waiting for the presence of bowel sounds have shown an earlier return of bowel function. 4 Because the recovery for a cesarean will be 6 weeks or longer, the nurse will encourage the family to help with infant care and housework. 5 Because the patient has an abdominal incision, the nurse needs to provide teaching for a diet that will promote healing.

A postpartum patient states, "I am really in pain." For which sources of pain will the nurse specifically assess the patient? Select all that apply. 1. Uterine contractions 2. Perineal trauma 3. Breast engorgement 4. Hemorrhoids 5. General soreness

1,2,3,4,5 The nurse will specifically assess for uterine contractions or afterpains being a source of pain. 2 The nurse will specifically assess for perineal trauma being a source of pain. Perineal trauma includes episiotomy, lacerations, and/or ecchymosis. 3 The nurse will specifically assess for breast engorgement as being a source of pain. Breastfeeding mothers may also have nipple pain caused by improper nipple latching by the neonate. 4 The nurse will specifically assess for hemorrhoids as being a source of pain. 5 The nurse will specifically assess for general soreness as being a source of pain.

The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments are covered by REEDA? Select all that apply. 1. Perineal coloration 2. Suture line appearance 3. Amount of swelling 4. Description of discomfort 5. Soft-tissue trauma

1,2,3,5 -The acronym REEDA stands for redness, edema, ecchymosis, discharge, and approximation of edges of episiotomy or laceration. Redness is indicative of perineal coloration. 2 The acronym REEDA stands for redness, edema, ecchymosis, discharge, and approximation of edges of episiotomy or laceration. Suture line appearance is indicative of approximation of edges of episiotomy or laceration. 3 The acronym REEDA stands for redness, edema, ecchymosis, discharge, and approximation of edges of episiotomy or laceration. The amount of swelling is indicative of edema. The acronym REEDA stands for redness, edema, ecchymosis, discharge, and approximation of edges of episiotomy or laceration. Soft-tissue trauma is frequently accompanied by bruising and is indicative of ecchymosis.

During a vaginal delivery, the primary care provider (PCP) notices greenish yellow coloration on the fetal head during crowning. Intrapartum suctioning is performed as soon as the fetus's head is delivered. The nurse understands the aspiration of meconium will have which effects on the neonate's respiratory function? Select all that apply. 1. Result in airway obstruction 2. Contribute to pulmonary hypertension 3. Result in chemical pneumonitis 4. Create strain on cardiac function 5. Cause surfactant dysfunction

1,2,3,5 Meconium aspiration syndrome (MAS) will result in airway obstruction, which is relative to the amount and consistency of the aspirated meconium. 2 Due to airway obstruction related to MAS, there is a high risk for the development of pulmonary hypertension. 3 Chemical pneumonitis is inflammation of the bronchial structures of the lungs caused by chemicals and/or substances that are foreign to the lungs. The presence of meconium or the medications used to treat MAS could be sources for the condition. 5 If the meconium is aspirated deeply enough, the air sacs may be coated with the aspirate, which will interfere with the functioning of surfactant

Following a cesarean birth, intrathecal morphine is administered to the patient for postoperative pain management. Of which fact about intrathecal morphine therapy is the nurse aware? Select all that apply. 1. An anesthesiologist or certified registered nurse anesthetist (CRNA) administers it intrathecally. 2. The nurse needs to closely monitor for common side effects. 3. The recommended dose is 10 to 15 mg. 4. The drug produces generalized central nervous system (CNS) depression. 5. The drug alters perception of and response to painful stimuli.

1,2,4,5 Intrathecal morphine is always administered to the patient by an anesthesiologist or CRNA. 2. The nurse will need to closely monitor for side effects of the drug. Common side effects include respiratory depression, itching, hypotension, nausea and vomiting, and urinary retention The nurse needs to be aware that intrathecal morphine will cause generalized CNS depression. 5 Intrathecal morphine is effective because it alters perception of and response to painful stimuli.

The nurse is aware that there are multiple classifications for cesarean deliveries. Which situations does the nurse classify as an unscheduled cesarean birth? Select all that apply. 1. The cervix fails to fully dilate after prolonged labor. 2. There is evidence of a prolapsed cord with membrane rupture. 3. Patient had a previous cesarean delivery. 4. Patient has a preexisting cardiac health condition. 5. There is recognition of placenta previa with mild bleeding.

1,2,4,5 When the cervix fails to fully dilate after prolonged labor, an unplanned nonurgent cesarean birth is performed. 2 Evidence of a prolapsed cord with membrane rupture is a complication requiring an emergent cesarean delivery. The patient with a preexisting cardiac health condition is usually scheduled for a planned cesarean delivery. The patient is at risk during labor and/or vaginal birth. 5. Recognition of placenta previa with mild bleeding is a reason for an urgent cesarean birth because of the need for rapid delivery of the fetus.

The nurse-manager on a labor and delivery unit is monitoring the reasons for cesarean births at the facility. Which reasons contribute to the high rates of cesarean births? Select all that apply. 1. Fetuses in breech position unable to deliver vaginally 2. Decreasing rate of malpractice litigation with cesarean birth 3. Incidences of women of older maternal age getting pregnant 4. Increased number of elective or maternal request cesareans 5. Presence of nonreassuring fetal tracings during labor

1,3,4,5 Fetuses in breech position that cannot be delivered vaginally are delivered by cesarean, which accounts for 17% of the cesarean births in the United States. Increase in the maternal age at delivery increases the rate of cesarean births. However, this reason accounts for between 4% and 5% of cesarean births. 4. Increase in the number of cesarean deliveries on maternal request increases the overall rate; however, this reason accounts for only 3% of the cesarean births in the United States. 5 The presence of nonreassuring fetal tracings during labor accounts for 23% of cesarean births.

The nurse is making a plan of care for a patient who is in the first 24-hour period past a cesarean delivery. Which interventions will the nurse include in regards to medications? Select all that apply. 1. Continue a daily stool softener. 2. Provide prophylaxis antibiotics. 3. Ensure the availability of naloxone. 4. Manage pain with morphine. 5. Administer RhoGAM if needed.

1,3,4,5 Within the first 24 hours and beyond, the nurse will continue administration of a daily stool softener. Constipation related to opiate pain control is common. Naloxone is administered for any signs of morphine overdose. 4. Following a cesarean, morphine is administered for management of post-surgery pain. 5. If the mother is Rh-negative, RhoGAM is given within the first 24 hours.

The nurse is performing a uterus assessment on a patient who is 20 hours' postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does not respond to uterine massage, which actions does the nurse implement? Select all that apply. 1. Assist the patient to the bathroom to void. 2. Assist the patient to lay in the left lateral position while assessing vital signs. 3. Administer oxytocin as prescribed. 4. Place an emergency call to the health-care provider (HCP). 5. Make the patient nothing by mouth (NPO) for surgery.

1,3,5 Because of the displacement of the uterus to the left, the nurse concludes that a full bladder may be the cause. The nurse needs to assist the patient to the bathroom to void. When the uterus is boggy and bleeding is moderate, the nurse will administer oxytocin as prescribed in the HCP's postpartum orders. If the patient does not respond to nursing and prescribed interventions, the nurse may make the patient NPO for anticipated surgery. The lack of response may indicate complications such as retained placental tissue or birth trauma. Continued uterine atony can lead to postpartum hemorrhage and requires assessment and potentially further treatment by the woman's HCP

The nurse is providing discharge teaching for the patient related to prevention of future pregnancy. The following statement by the patient indicates additional education is required. 1. "I will start using a barrier method once my menstrual cycle begins." 2. "Breastfeeding is not an effective form of birth control and I should use another method when I resume sexual activity." 3. "Long-acting reversible contraception (ACR) such as an intrauterine device (IUD) is highly effective in preventing unwanted pregnancy." 4. "Withdrawal has a high failure rate and does not protect against sexually transmitted infections (STIs)."

1. "I will start using a barrier method once my menstrual cycle begins." -Ovulation can precede the return of menses, so the patient is at risk for getting pregnant before the time when her menstrual cycle begins

The nurse is providing care to a patient who is in labor. The patient's membranes rupture spontaneously, and the nurse notices meconium-stained amniotic fluid. Which actions does the nurse immediately perform? Select all that apply. 1. Alert the neonatal team of a possible meconium aspiration neonate. 2. Promote fetal well-being by placing the patient on her left side. 3. Notify the primary care provider (PCP) about the presence of meconium. 4. Administer oxygen to the mother to help prevent fetal hypoxia. 5. Test the stained fluid for percentage of meconium content.

1. Alert the neonatal team of a possible meconium aspiration neonate. 3. Notify the primary care provider (PCP) about the presence of meconium. The nurse will immediately inform the neonatal resuscitation team that they may expect a meconium aspiration neonate. It is imperative that resuscitation occur immediately in order to avoid or decrease respiratory complications. The nurse immediately notifies the PCP about the meconium-stained amniotic fluid, which may be an indicator of fetal distress

The nurse is assessing a multiparous woman who is 8 hours' postpartum. Her fundus is located 2cm above the umbilicus and shifted slightly to the right. What education would the nurse provide to the patient related to this assessment finding? 1. Emptying the bladder frequently will help to reduce displacement of the uterus. 2. The uterus is normally above the fundus on the first postpartum day and will significantly reduce in size within the next 24 hours. 3. Beginning an infusion of oxytocin will help to contract the uterus below the umbilicus. 4. Breastfeeding can cause the uterus to increase in size and shift it to the right.

1. Emptying the bladder frequently will help to reduce displacement of the uterus. A uterus that is shifted to the side may indicate a distended bladder which interferes with uterine contractibility and places the woman at risk for uterine atony. Emptying the bladder frequently will help to reduce displacement of the uterus

The nurse in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient? 1. Express milk by a breast pump or manually if the infant is unable to nurse. 2. Wear a supportive bra for 24 hours a day. 3. Run warm water over breasts while in the shower. 4. Avoid taking analgesics unless absolutely necessary for comfort.

1. Express milk by a breast pump or manually if the infant is unable to nurse. -Expressing milk with a breast pump or manually is specifically helpful to the breastfeeding patient and important for whenever the infant is not able to nurse (such as with premature infants). The process can help relieve breast engorgement, maintain a milk supply for the neonate/infant who cannot suckle at the breast, and/or provide breast milk for the neonate/infant who is separated from the mother

The most common complication of childbirth for women having cesarean birth is: 1. Hemorrhage requiring a blood transfusion 2. Unplanned hysterectomy 3. Ruptured uterus 4. Retained surgical sponges

1. Hemorrhage requiring a blood transfusion The most common complication of childbirth for women having cesarean birth is hemorrhage requiring a blood transfusion.

The nurse is providing teaching to a patient who is breastfeeding a newborn. The patient expresses interest in maintaining a healthy nutritional status for both her and her baby. Which information does the nurse present to meet the patient's need? Select all that apply. 1. Increase caloric intake by 500 to 1,000 per day. 2. Avoid the intake of processed foods. 3. Abstain from the intake of alcohol. 4. Eat fresh fruits and vegetables. 5. Drink 2 to 3 liters of fluid each day.

1. Increase caloric intake by 500 to 1,000 per day. 5. Drink 2 to 3 liters of fluid each day. The lactating mother should increase her caloric intake by 500 to 1,000 calories daily. The lactating mother will need to drink approximately 2 to 3 liters of fluid daily.

A patient is being prepared for an unplanned cesarean section. Which pre-procedure information is most important for the nurse to report before the administration of regional anesthesia? 1. Laboratory value indicating a low platelet count 2. Inability of the patient to sit on the bedside and flex forward 3. Hypovolemia corrected with IV fluid administration 4. History of patient experiencing headaches after a spinal

1. Laboratory value indicating a low platelet count The most important information to be reported by the nurse is the laboratory value that indicates a low platelet count. It is the most common contraindication, especially with women who have preeclampsia and/or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome

The nurses in a labor and delivery unit are concerned about the high incidence of cesarean deliveries at their facility and initiate an internal study. Which is the most likely condition the nurses will recognize as a contributor to the rate of cesarean births? 1. Policies and parameters for cesarean need to be reviewed and refined. 2. The facility has a high rating for managing high-risk pregnancies. 3. Community education about the advantages of vaginal birth is deficient. 4. The incidence of maternal requests for cesarean delivery is increasing.

1. Policies and parameters for cesarean need to be reviewed and refined. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress as a means to reduce the numbers of cesarean births. Clinical improvement strategies with careful examination of labor management practices are important.

The nurse in labor and delivery notices an increase in the number of women requesting cesarean births. Which are the parameters and criteria used when making the decision to perform a cesarean delivery on maternal request (CDMR)? Select all that apply. 1. Procedure is performed after 39 weeks' gestation. 2. Patient is willing to defer from legal litigation. 3. Patient is aware of possible neonatal complications. 4. Mother is planning to only have one child. 5. Patient is able to self-pay for the procedure.

1. Procedure is performed after 39 weeks' gestation. 3. Patient is aware of possible neonatal complications. Because of the increased risk for neonatal complications, the patient needs to understand that CDMR does not occur before 39 weeks' gestation. Part of the parameters and criteria relative to a CDMR is that the patient recognizes that the fetus is at risk for respiratory distress, hypothermia, hypoglycemia, and/or neonatal intensive care unit (NICU) admission.

When assisting with a vacuum-assisted vaginal delivery, the nurse is aware that adherence to which guidelines for the vacuum device will minimize the nurse's liability in vacuum-assisted vaginal births? Select all that apply. 1. Pump up the vacuum manually to the pressure indicated on the pump. 2. Recognize that cup detachment (pop off) is a warning sign. 3. The cup should not be on the fetal head for longer than 5 to 10 minutes. 4. The procedure is timed from insertion of the cup into the vagina until the birth. 5. Understand that pressure should be released between contractions.

1. Pump up the vacuum manually to the pressure indicated on the pump. 2. Recognize that cup detachment (pop off) is a warning sign. 5. Understand that pressure should be released between contractions. Pump up the vacuum manually to the pressure indicated on the pump, not to exceed 500 to 600 mm Hg. (2) The nurse needs to be aware that cup detachment (pop off) is a warning that too much ineffective force is being exerted on the fetal head. (4) .The procedure is timed from point of insertion of the cup into the vagina until the birth. If the vacuum-assisted delivery does not occur after three attempts within 15 to 20 minutes, cesarean is indicated. (5) It is important to understand that pressure should be released between contractions; retention of unnecessary pressure increases the risk for fetal injury.

The nurse is reviewing the medical record for a patient who is postpartum. The nurse notices the patient is rubella-nonimmune. Which information does the nurse present to the patient? Select all that apply. 1. Maternal immunization carries over to the neonate. 2. The patient should be immunized before discharge. 3. If given rubella vaccination, breastfeeding should be avoided for 24 hours after immunization. 4. There are risks to the fetuses of any future pregnancies. 5. If given rubella vaccination, pregnancy should be avoided for 4 weeks.

2,4,5 The patient should be immunized before discharge so that immunity is established before the possibility of another pregnancy. Women cannot be immunized during pregnancy. Fetuses exposed to rubella during the first trimester are at risk for birth defects that include deafness, blindness, heart defects, and mental retardation. 5. Although the risk of a fetus developing birth defects from the vaccine is extremely low, the patient is advised to avoid pregnancy for 4 weeks.

A postpartum patient calls the obstetric (OB) office 8 days following a vaginal delivery. The patient reports concern regarding vaginal bleeding. Which patient-reported symptom causes the nurse concern? 1. Increased flow noticed with physical activity 2. A description of the lochia as being red in color 3. Discharge that is noted to have a fleshy odor 4. Bleeding that is described as brown in color

2. A description of the lochia as being red in color The lochia during the period of 4 to 10 days is described as lochia serosa (pink or brown color). The nurse will be concerned if the patient reports lochia that is red in color, which is indicative of bleeding

The nurse is providing care to a patient who is diagnosed with dystocia related to hypertonic uterine dysfunction. Which medical intervention does the nurse implement for this patient? 1. Explain to the family that the patient needs rest before labor continues. 2. Administer morphine to decrease contractions and promote uterine rest. 3. Assist the patient to relax by providing back and neck massage. 4. Discuss how the patient's fear is interfering with the progression of labor

2. Administer morphine to decrease contractions and promote uterine rest. The medical intervention of administering a pain medication, such as morphine, will decrease uterine contractions and allow the uterus to rest.

Included in the definition of tachysystole is: 1. Contraction duration of less than 40 seconds 2. Contraction frequency of greater than 5 in 10 minutes 3. Contraction intensity of less than 80 mm Hg 4. Resting tone of less than 18 mm Hg

2. Contraction frequency of greater than 5 in 10 minutes Tachysystole is excessive uterine activity and can be either spontaneous or induced. It is defined as more than five contractions in 10 minutes, averaged over 30 minutes.

The nurse is discussing contraception with a breastfeeding woman and her husband before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend? 1. Lactational amenorrhea method 2. Depo-Provera 3. Oral estrogen/progesterone pill 4. Natural family planning

2. Depo-Provera Depo-Provera is a likely suggestion by the nurse. This method has a 3% failure rate, is injectable every 3 months, and has few non-life-threatening side effects. It may result in delayed fertility

The nurse is providing care to a patient who is at 41 weeks' gestation. Which factor about the patient does the nurse consider as an indication of late-term or post-term pregnancy? 1. Patient's multiparity status 2. Fetus is identified as a male 3. Delivered two babies at 38 weeks 4. History of regular menstruation

2. Fetus is identified as a male Risk factors for post-term pregnancy include carrying a male fetus

The nurse is assisting with the preparation of a patient admitted for a planned cesarean birth. The patient has signed the consent form and discussed the elected regional anesthesia with the nurse anesthetist. Which is the most important action for the nurse related to anesthesia? 1. Verify the patient has been nothing by mouth (NPO) for 6 to 8 hours. 2. Obtain a baseline fetal heart rate (FHR) monitor strip. 3. Administer preoperative medications per orders. 4. Start an IV line and administer an IV fluid as ordered.

2. Obtain a baseline fetal heart rate (FHR) monitor strip. Obtaining a baseline FHR monitor strip for at least 20 minutes before the administration of anesthesia is the most important nursing action. Another 20-minute strip will be obtained after the administration of the anesthesia. This comparison makes fetal monitoring more effective.

The nurse is providing care in a post-anesthesia care unit (PACU) for a patient who just delivered a neonate via cesarean section. The patient reports tightness in her chest. Assessment findings include tachypnea, hypotension, and decreasing oxygen saturation levels. Which complication does the nurse report to the health-care provider (HCP)? 1. Postpartum hemorrhage 2. Pulmonary embolism 3. Surgical-site infection 4. Developing endometritis

2. Pulmonary embolism The patient's manifestations are classic for pulmonary embolus. Other assessment findings will include dyspnea, shortness of breath, and hypotension

A patient who is at 39 weeks' gestation is scheduled for amniotomy. The nurse is aware that which criteria must be met before the procedure? 1. Prior amniotic fluid leakage must be validated before the procedure. 2. The fetal head is currently engaged in the maternal pelvis. 3. The nurse must have certification to perform the procedure. 4. Ultrasound indicates the umbilical cord is away from the cervix.

2. The fetal head is currently engaged in the maternal pelvis. An important criterion for performing an amniotomy is for the fetal head to be engaged in the maternal pelvis. Lack of engagement will result in a prolonged labor and/or an increased risk for infection.

The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis? 1. To prevent uterine prolapse 2. To prevent uterine inversion 3. To prevent uterine hemorrhage 4. To prevent uterine movement

2. To prevent uterine inversion When palpating the patient's uterus 12 hours' postpartum, the nurse supports the lower uterine segment by placing one hand just above the symphysis pubis. Pregnancy stretches the ligaments that hold the uterus in place, and fundal pressure could result in uterine inversion.

The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system? 1. Patient reports being cold related to a 400 mL blood loss during a vaginal birth 2. White blood cell (WBC) laboratory level of 30,000/mm a few hours after delivery 3. A normal postpartum hemoglobin laboratory value of less than 11 g/dL 4. Risk for hemorrhage due to decrease in circulating clotting factors

2. White blood cell (WBC) laboratory level of 30,000/mm a few hours after delivery The nurse is aware that a WBC laboratory level of 30,000/mm a few hours after delivery is normal and is the result of the stress of labor and birth.

A patient who is expecting her first baby tells the nurse, "I am afraid of the whole birth experience and plan to ask the doctor for a cesarean delivery." Which response by the nurse is most appropriate? 1. "Most women avoid cesarean births unless it is an emergency." 2. "I will get you some material about how labor pain is managed." 3. "Cesarean will cause you issues with additional pregnancies." 4. "I suggest you talk with the physician and get another opinion."

3. "Cesarean will cause you issues with additional pregnancies." The nurse needs to inform the patient that if additional pregnancies are desired, cesarean delivery risks increase with each additional pregnancy. Risk for placenta previa, placenta accreta, and gravid hysterectomy rises with each cesarean delivery.

In preparation for a cesarean birth, the nurse expects which medical-based preoperative interventions? Select all that apply. 1. Assessment of the woman's knowledge and educational needs 2. Verification that the woman has been nothing by mouth (NPO) for 6 to 8 hours before surgery 3. Administration of narrow-spectrum prophylactic antibiotics 4. Assessment for risk of venous thromboembolism (VTE) 5. Prescription for sequential compression devices before surgery

3. Administration of narrow-spectrum prophylactic antibiotics 4. Assessment for risk of venous thromboembolism (VTE) 5. Prescription for sequential compression devices before surgery Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes before the skin incision for any cesarean. If the cesarean is emergent, the antibiotics can be administered during or immediately after the procedure. Prescription of medications is a medical-based intervention. 4 This is correct. Performing an assessment for risk of VTE and classifying the woman based on VTE classification guidelines is a medical-based intervention. Preoperative anticoagulant therapy may be necessary for women classified as moderate or high risk or with a history of recurrent thrombosis. 5 This is correct. Application of sequential compression devices before surgery is to promote lower extremity circulation and aid in the prevention of blood clots. The nurse performs the action based on a medical prescription.

The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform before assessing the patient's uterus? 1. Place the patient on the left side. 2. Administer a dose of oxytocin. 3. Ask the patient to void. 4. Assess the passage of lochia.

3. Ask the patient to void. The nurse needs to have the patient void before palpating the uterus in order to accurately assess uterine placement and tone. An overdistended bladder can result in uterine displacement and atony

An emergency cesarean is being implemented. The patient describes tingling in her ears and a metallic taste with the administration of regional anesthesia. The nurse is aware that which incidence has occurred? 1. Manifestation of maternal respiratory depression related to anesthesia 2. Maternal hypotension is occurring related to administration of anesthesia 3. Inadvertent injection of the anesthetic agent into the maternal bloodstream4. Expected manifestations related to anesthetic medications are present

3. Inadvertent injection of the anesthetic agent into the maternal The patient is exhibiting cardinal signs related to inadvertent injection of the anesthetic agent into the maternal bloodstream. The patient may also exhibit hypotension that can lead to loss of consciousness and cardiac arrest.

A medication given to women experiencing a prolonged latent phase to produce a period of rest or sleep is: 1. Butorphanol (Stadol) 2. Promethazine hydrochloride (Phenergan) 3. Morphine sulfate 4. Fentanyl (Sublimaze)

3. Morphine sulfate -Morphine is the medication given to women experiencing a prolonged latent phase to produce a period of rest or sleep.

The nurse is providing care for a patient in the second phase of labor. After more than 4 hours of pushing, the nurse suspects fetal dystocia. Which is the greatest risk related to the nurse's suspected complication? 1. Greater risk for maternal lacerations 2. Fetal injury confirmed by the presence of bruising 3. Neonatal asphyxia related to prolonged labor 4. Increased consideration for a cesarean delivery

3. Neonatal asphyxia related to prolonged labor The greatest concern related to fetal dystocia is the complication of fetal asphyxia related to a prolonged labor.

The nurse is providing care for a patient who is at 42 weeks' gestation. The patient's primary care provider (PCP) is suggesting induction, but the patient is resistant. Which facts can the nurse provide if the patient asks about allowing labor to start spontaneously? Select all that apply. 1. Maternal death rate is higher if the pregnancy is continued beyond 42 weeks. 2. Post-term fetuses are prone to developmental delays related to uterine hypoxia. 3. Stillbirth or newborn death increases in pregnancies beyond 42 weeks. 4. There is a greater chance of developing complications because of larger fetal size. 5. Postmature fetuses have decreased subcutaneous fat and lack vernix and lanugo.

3. Stillbirth or newborn death increases in pregnancies beyond 42 weeks. 4. There is a greater chance of developing complications because of larger fetal size. 5. Postmature fetuses have decreased subcutaneous fat and lack vernix and lanugo. -One of the greatest concerns about post-term pregnancy is the increased risk of stillbirth or infant death. 4. The fetus who is post-term is most likely to exhibit macrosomia, a condition that contributes to a higher risk for complications associated with both the mother and fetus. 5 Postmature fetuses have decreased subcutaneous fat and lack vernix and lanugo. However, although the nurse can present this as factual information, it is likely

The nurse is assisting the primary care provider (PCP) with a vacuum-assisted delivery because of a prolonged second stage of labor. The nurse will inform the PCP when which guideline of the procedure is met? 1. Extension of the episiotomy is performed. 2. Signs of fetal compromise have resolved. 3. The "three-pull rule" has been achieved. 4. Patient is under full anesthesia status.

3. The "three-pull rule" has been achieved. The nurse will inform the care provider when the "three-pull rule" guideline for vacuum-assisted delivery has been achieved. There should be a maximum of three attempts for a period of 15 minutes.

The nurse in the post-delivery unit is encouraging skin-to-skin contact for a mother and neonate after cesarean delivery. Which action, if noticed by the nurse, requires immediate intervention by the nurse? 1. The mother is sitting up with the neonate prone on her chest. 2. The neonate is prone on the mother's chest and facing to the side. 3. The mother is supine with the neonate prone on her chest. 4. The neonate is prone with mother resting in semi-Fowler's position.

3. The mother is supine with the neonate prone on her chest. Neonates are susceptible to sudden respiratory and cardiac arrest during the first few hours of life. Newborns in prone position on the mother's chest, especially if the mother is on her back, are especially susceptible to sudden unexpected newborn collapse (SUPC). The nurse will intervene immediately.

A patient at 34 weeks' gestation is in labor with twins. The primary care provider (PCP) decides the fetuses need to be delivered by cesarean. Which medical and nursing interventions will be in place for this delivery? Select all that apply. 1. The fetal heart rate (FHR) for the two fetuses is monitored alternately. 2. The usual personnel to attend delivery are arranged. 3. The placement of a large-bore IV access is ensured. 4. A hospital with a Level II or III nursery is selected. 5. Delivery is attended by two medical personnel.

3. The placement of a large-bore IV access is ensured. 4. A hospital with a Level II or III nursery is selected. 5. Delivery is attended by two medical personnel. The nurse will make sure that a large-bore IV access is in place for fluid replacement in case of hemorrhage or need for emergency fluid replacement and anesthesia administration. 4. Due to the possibilities of fetal distress or need of special care related to immaturity, the cesarean needs to be performed in a hospital with either a Level II or III nursery. 5 For multiple births, either two experienced obstetricians or one obstetrician and a board-certified midwife will attend the delivery

The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide? 1. The signs and symptoms of uterine infection 2. The signs and symptoms of a boggy uterus 3. The signs and symptoms of secondary hemorrhage 4. The signs and symptoms of postpartum depression

3. The signs and symptoms of secondary hemorrhage It is most important for the nurse to provide teaching regarding the signs and symptoms of secondary hemorrhage, which often occurs after the patient is discharged. The patient needs to understand the normal progression of lochia and uterine involution, and report abnormal amounts of bleeding.

In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply. 1. Bleeding that soaks a pad per hour 2. A bad headache with vision changes 3. Thoughts of hurting self or baby 4. Signs an incision is not healing 5. Pain in the chest

3. Thoughts of hurting self or baby 5. Pain in the chest The AWHONN acronym states the mother should call 911 immediately if she has thoughts of self-harm or harm to her baby. This can be indicative of severe postpartum depression or psychosis. The AWHONN acronym states the mother should call 911 immediately if she has pain in the chest as it can be indicative of a pulmonary embolism or cardiac issue.

The nurse is completing postpartum discharge teaching to a client who had no immunity to rubella and was given the rubella immunization. Which of the following statements by the client indicates understanding of the teaching? 1. "I was given the vaccine because my newborn is Rh positive." 2. "The rubella immunization should be given with each pregnancy within 72 hours of delivery." 3. "If I do not develop immunity to rubella, I should be immunized during the first trimester of my next pregnancy." 4. "I should avoid pregnancy for 4 weeks after being immunized."

4. "I should avoid pregnancy for 4 weeks after being immunized." Women who are immunized with rubella vaccination should avoid pregnancy for 4 weeks, although the risk of the fetus developing birth defects from the vaccine is extremely low.

A patient who is 12 hours' postpartum after a vaginal delivery continues to have difficulty in initiating urination. The nurse is aware that an integrative method used when a woman is unable to void is peppermint oil. In which manner will the peppermint oil be used? 1. A thin layer is applied to the urinary meatus. 2. A small amount on toilet paper is added to the toilet bowl. 3. A small amount is added to the water of a vaporizer. 4. A saturated cotton ball is placed in a "hat" on the toilet.

4. A saturated cotton ball is placed in a "hat" on the toilet. The nurse will place a cotton ball saturated with peppermint oil in a "hat" used to collect urine when the patient voids in the toilet. A small amount of water is added to the "hat," and the resulting vapors have a relaxing effect on the urinary sphincter.

A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence? 1. The efforts of the uterus to return to a prepregnancy condition 2. The presence of intense afterbirth pains related to multiparity 3. An expected response to the daily administration of oxytocin 4. An increase in oxytocin release related to the newborn suckling

4. An increase in oxytocin release related to the newborn suckling -The suckling of a newborn during breastfeeding will stimulate an increased release of oxytocin, which in turn stimulates the uterus to remain contracted.

A patient arrives at labor and delivery for the induction labor for her first child. The patient tells the nurse, "I can't believe how easy this is just to pick a day, sign a paper, and have a baby." Which action does the nurse take before the induction process? 1. Report an incidence of probable malpractice by the health-care provider (HCP). 2. Check the patient's chart for an informed consent. 3. Explain the possible complications of induction to the patient. 4. Call the HCP to validate patient understanding.

4. Call the HCP to validate patient understanding. The nurse needs to call the HCP and validate patient understanding about potential risks and complications related to labor induction.

A patient who is pregnant expresses a desire to attempt a vaginal delivery after a cesarean birth 2 years before. The primary care provider (PCP) initiates trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC) screening. The nurse is aware that which patient information will likely disqualify the patient for VBAC? 1. A low transverse uterine scar 2. Patient asks multiple questions 3. First labor needed to be induced 4. Cesarean due to pelvic abnormalities

4. Cesarean due to pelvic abnormalities The fact that the patient had a cesarean for pelvic abnormalities will disqualify her for TOLAC/VBAC; pelvic abnormalities are permanent

A high probability of successful induction of labor is associated with a Bishop score of: 1. Greater than 2 2. Greater than 4 3. Greater than 6 4. Greater than 8

4. Greater than 8 A Bishop's score greater than 8 generally confers the same likelihood of vaginal delivery with induction of labor as that following spontaneous labor, and thus has been considered to indicate a favorable cervix.

The nurse is providing care for a prenatal patient who is told she will require a cesarean delivery because of cephalopelvic disproportion. Which explanation of the condition will the nurse provide to the patient? 1. The patient has a preexisting medical condition that supports cesarean birth. 2. The patient had a surgery with an incision through the myometrium of the uterus. 3. The placenta is implanted in an unfavorable position in the uterus. 4. The size and/or shape of either the fetal head or patient pelvis is an issue.

4. The size and/or shape of either the fetal head or patient pelvis is an issue. The patient requires a definition of cephalopelvic disproportion, which before labor includes the determination that the size and/or shape of either the fetal head or patient pelvis is an issue.

The nurse is monitoring a patient who has been in prolonged labor. Which assessment finding will result in the nurse notifying the health-care provider (HCP) about the development of an emergent situation requiring a cesarean delivery? 1. Recognition of a Category II fetal heart rate (FHR) pattern 2. Maternal exhaustion from prolonged uterine activity 3. Maternal blood pressure indicative of hypotension 4. Increased maternal temperature related to infection

1. Recognition of a Category II fetal heart rate (FHR) pattern The nurse will notify the HCP about recognition of a Category II FHR pattern, which is an indication of fetal intolerance of labor

The terminology intrauterine inflammation or infection or both or Triple I is now used instead of the term _______.

chorioamnionitis

The nurse understands that logically cesarean births are an influential factor related to the overall incidence of cesarean births. _______

previous

The first sign of shoulder dystocia is the _________ of the fetal head against the maternal perineum after delivery of the head.

retraction

After pregnancy and birth, a mother may notice a condition called diastasis recti abdominis, which is a(n) of the rectus muscle. _______

separation

The nurse is providing care for a primiparous patient in active labor. Cervical dilation has progressed 0.5 cm in 2 hours. The intrauterine pressure catheter reading is 20 mm Hg. Which action does the nurse anticipate next? 1. Rupture of uterine membranes by the nurse 2. Preparation for a cesarean delivery due to signs of fetal distress 3. Medicating the patient with pain medication to promote uterine rest 4.Augmentation of labor with oxytocin per health-care provider's (HCP's) order

4.Augmentation of labor with oxytocin per health-care provider's (HCP's) order The action the nurse will anticipate is the augmentation of labor with administration of the prescribed oxytocin.

The nurse is providing care for a patient who is admitted for cervical ripening. The health-care provider (HCP) has prescribed the use of a hygroscopic dilator. Which conclusion is the nurse likely to draw from the prescribed method of cervical ripening? 1. The method may be indicative of fetal demise. 2. The patient has a history of cesarean childbirth. 3. This method is quicker than hormonal ripening. 4. This patient is being treated for active herpes.

1. The method may be indicative of fetal demise. Currently, hygroscopic dilators are used primarily during pregnancy termination rather than for cervical ripening in term pregnancies. Pregnancy termination may be necessary due to fetal demise.

The nurse is attending to a patient who just delivered a term fetus who was stillborn. Which nursing interventions will the nurse use to provide emotional support to the couple? Select all that apply. 1. Cut a lock of the neonate's hair and get foot and hand prints. 2. Express the belief that a little angel was sent to heaven. 3. Allow parents unlimited time to hold and touch the neonate. 4. Inquire if the patient had any warning of fetal death. 5. Ask the parents what name they are giving their baby.

1,3 The parents need to have mementoes of the baby. Items may include photographs of the infant, locks of hair, name bracelets, footprints, measuring tape, name certificates, quilts, clothing, poems, or sympathy cards. The neonate is wrapped in a blanket and given to the parents to hold and touch for as long as they wish. Other family members may be included as the parents wish

The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots? 1. To determine the presence of tissue 2. To validate the presence of clotting 3. To obtain an accurate description 4. To document the number of clots

1. To determine the presence of tissue The nurse collects the large clots in order to examine them for the presence of tissue, which indicates retained placenta tissue. Retained placental tissue can interfere with uterine involution and lead to excessive bleeding.

The nurse is assessing patients who are postpartum. Which patients does the nurse identify as being at increased risk for respiratory complications? Select all that apply. 1. The patient with leg pain and swelling 2. The patient who received large amounts of IV fluid due to blood loss 3. The patient with a preexisting diagnosis of diabetes mellitus 4. The patient who delivered a neonate after regional anesthesia 5. The patient with preeclampsia treated with magnesium sulfate

1,2,5 The nurse recognizes that the patient with leg pain and swelling may indicate venous thrombosis and therefore is a risk for developing a pulmonary embolus. 2. The patient who receives a large amount of IV fluids because of blood loss is at risk for respiratory system complications related to the potential for fluid overload. Treating a patient with preeclampsia with magnesium sulfate places the patient at an increased risk for respiratory system complications.

The nurse in labor and delivery is preparing to initiate labor induction with the administration of oxytocin. After research about oxytocin, the nurse is aware of which fact about the drug? 1. Synthetic oxytocin is identical to endogenous oxytocin. 2. Hypothalamus stimulation increases circulating oxytocin. 3. The half-life of oxytocin is 1 hour, supporting close monitoring. 4. Action from IV oxytocin administration is less than 1 minute.

1. Synthetic oxytocin is identical to endogenous oxytocin The nurse is aware from drug research that synthetic oxytocin is identical to endogenous oxytocin.

Before discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations? 1. Vaccinating the mother will protect the neonate from serious illnesses. 2. Discharge with a neonate is discouraged if the mother is not vaccinated. 3. The mother's immune system has been suppressed during pregnancy. 4. Vaccination is more easily accomplished while the mother is under medical care

1. Vaccinating the mother will protect the neonate from serious illnesses. When the mother is vaccinated for rubella, hepatitis B, pertussis, and influenza, the neonate is also less likely to be infected with or affected by these diseases. Hepatitis B, pertussis, and influenza can be life-threatening for a neonate. The mother should be immunized for rubella to avoid contracting the disease during a future pregnancy