maternal exam 6
A pregnant patient has been administered terbutaline (Brethine) as prescribed. The nurse finds that the patient has a heart rate of 140 beats/min and complains of chest pain. What is the best nursing action in this situation? 1 Administer propranolol (Inderal). 2 Administer intravenous fluids. 3 Administer 1 g calcium gluconate. 4 Inform the primary health care provider (PHP)
4 Inform the primary health care provider (PHP)
A pregnant patient is suspected to have preterm labor. The nurse is preparing to collect the vaginal discharge for conducting the fetal fibronectin test. What interventions are necessary before collecting the sample to ensure accuracy of the test? Select all that apply. 1 Check for the presence of vaginal bleeding in the patient. 2 Assess the patient to see if the amniotic membranes have ruptured. 3 Ask the patient to empty the bladder before collecting the sample. 4 Ask about history of sexual intercourse in the past 24 hours. 5 Instruct the patient to drink 2 glasses of water.
A pregnant patient is suspected to have preterm labor. The nurse is preparing to collect the vaginal discharge for conducting the fetal fibronectin test. What interventions are necessary before collecting the sample to ensure accuracy of the test? Select all that apply. Correct 1 Check for the presence of vaginal bleeding in the patient. Correct 2 Assess the patient to see if the amniotic membranes have ruptured. Correct 4 Ask about history of sexual intercourse in the past 24 hours.
After a vaginal delivery, the patient reports perineal discomfort when sitting. What instruction should the nurse give the patient to relieve discomfort? 1 "Tighten your buttocks before sitting or rising." 2 "Support your body weight on the arms of a chair." 3 "Place a pillow behind your back." 4 "Always sit on an inflatable ring."
Correct 1 "Tighten your buttocks before sitting or rising."
The nurse tells the primary health care provider (PHP) that there is 15 mL of fetal blood in maternal circulation, as detected by Kleihauer-Betke test, in an Rh-negative patient. What does the nurse expect the PHP to prescribe to this patient? 1 300 mcg of intramuscular Rh immune globulin 2 400 mcg of intramuscular Rh immune globulin 3 100 mcg of intramuscular Rh immune globulin 4 200 mcg of intramuscular Rh immune globulin
Correct 1 300 mcg of intramuscular Rh immune globulin
A nonbreastfeeding postpartum patient reports a lump formation in the breast. Upon assessment, the nurse finds that the lumps are not restricted to a single place. What does the nurse expect to be the possible reason for this? 1 Accumulation of milk 2 Fibrocystic breast cancer 3 Temporary congestion of arteries 4 Temporary congestion of lymphatics
Correct 1 Accumulation of milk
The nurse is caring for a patient who has postpartum hemorrhage resulting from uterine atony. Which interventions would help identify and care for hypovolemic shock? Select all that apply. 1 Administering blood or blood products 2 Monitoring skin integrity 3 Administering analgesics to relieve pain 4 Administering oxytocin 5 Monitoring blood pressure
Correct 1 Administering blood or blood products Correct 2 Monitoring skin integrity Correct 4 Administering oxytocin
The pregnant patient reports severe pain in the midsection of the uterus. Following the assessment, the nurse finds that the patient has frequent uterine contractions (UCs) with cervix dilation up to 2 cm. Which nursing interventions does the nurse perform? Select all that apply. 1 Administers an analgesic to the patient 2 Administers zolpidem (Ambien) to the patient 3 Encourages the patient to take a warm shower 4 Administers oxytocin (Pitocin) to the patient 5 Provides hydrotherapy to the patient
Correct 1 Administers an analgesic to the patient Correct 2 Administers zolpidem (Ambien) to the patient Correct 3 Encourages the patient to take a warm shower
If a pregnant patient suspects signs and symptoms of preterm labor, which conditions would lead the patient to go to hospital immediately? Select all that apply. Correct 1 Fluid leakage from vagina 2 Upper abdominal pain 3 Nausea and vomiting Correct 4 Contractions every 10 minutes Correct 5 Presence of vaginal bleeding
Correct 1 Fluid leakage from vagina 4 Contractions every 10 minutes 5 Presence of vaginal bleeding
The nurse finds that a postpartum patient has high levels of prolactin. What could be the reason behind it? Select all that apply. 1 Increased breastfeeding 2 Increased progesterone 3 Decreased aldosterone 4 Decreased estrogen 5 Decreased suckling
Correct 1 Increased breastfeeding Correct 4 Decreased estrogen
The nurse is preparing to administer dexamethasone (Decadron) to a pregnant patient. Which nursing intervention should the nurse perform for safe administration of the drug? Select all that apply. 1 Inform the patient that it will be painful. 2 Administer the oral form if patient refuses injection. 3 Administer the drug by intramuscular injection. 4 Monitor blood pressure of the patient. 5 Assess blood glucose levels in the patient.
Correct 1 Inform the patient that it will be painful. Correct 3 Administer the drug by intramuscular injection. Correct 5 Assess blood glucose levels in the patient.
Which findings are a source of concern if noted during assessment of a woman who is 12 hours postpartum? Select all that apply. 1 Lochia rubra with foul odor 2 Pain in left calf with dorsiflexion of left foot 3 Bradycardia—pulse rate of 55 beats/min 4 Temperature of 100.4° F 5 Postural hypotension
Correct 1 Lochia rubra with foul odor Correct 2 Pain in left calf with dorsiflexion of left foot
The fetal fibronectin test of a pregnant patient is positive, and her cervical length is found to be 32 mm. What will the nurse interpret from these observations regarding the patient's pregnancy status? 1 Normal gestational labor 2 Indicated preterm labor 3 Spontaneous preterm labor 4 Miscarriage in the next week
Correct 1 Normal gestational labor
The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? Select all that apply. Correct 1 Previous cesarean birth Correct 2 Unstable coronary artery disease 3 History of three spontaneous abortions 4 Initial blood pressure of 132/87 Correct 5 Placenta previa
Correct 1 Previous cesarean birth Correct 2 Unstable coronary artery disease Correct 5 Placenta previa
Which assessment findings in a postpartum patient indicate the presence of infection? Select all that apply. 1 Pulse rate of 100 beats/min 2 Cracks on the nipples 3 Blood pressure of 120/80 mm Hg 4 Respiration rate of 20 breaths/min 5 Temperature of 100.8º
Correct 1 Pulse rate of 100 beats/min Correct 5 Temperature of 100.8º
What maternal physiological changes can be observed initially during the postpartum period? 1 Vaginal distention decreases. 2 Tachycardia occurs in the first 24 hours. 3 Cardiac output decreases in the first 24 hours. 4 Digestive processes slow immediately
Correct 1 Vaginal distention decreases.
The nurse observes that the newborn is responding well to the parent. Which behavior from the newborn did the nurse observe to come to this conclusion? The newborn: 1 Was dancing in tune with the parent's voice. 2 Looked at the wall upon hearing the parent's voice. 3 Was not kicking its legs in tune to the parent's voice. 4 Was not waving its arms in tune to the parent's voice
Correct 1 Was dancing in tune with the parent's voice.
The nurse finds that the infant is fussy and irritated after feeding. What does the nurse suggest that the patient do in order to comfort the infant? 1 "Sing and coo to the infant." 2 "Gently rub the infant's back." 3 "Establish eye contact with the infant." 4 "Gently stretch the arms and legs of the infant."
Correct 2 "Gently rub the infant's back."
What statement by a woman who just gave birth indicates that she knows what to expect about her menstrual activity after childbirth? 1 "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." 2 "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." 3 "I will not have a menstrual cycle for 6 months after childbirth." 4 "My first menstrual cycle will be heavier than normal and then will be light for several months after."
Correct 2 "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles."
The nurse is caring for an Asian patient who had a vaginal delivery. Which nursing intervention would be consistent with the patient's cultural practice regarding postpartum care? 1 Talk privately with the mother about caring for the newborn. 2 Ask the patient to not engage in any household activities. 3 Advise the patient to rest for a full 2 months after the birth. 4 Ask the patient to use the sitz iced bath for episiotomy pain relief.
Correct 2 Ask the patient to not engage in any household activities.
The nurse administers the prescribed nifedipine (Adalat) to a pregnant patient during labor to reduce uterine contractions (UCs). Which nursing action is the most appropriate after the drug administration? Monitoring the: 1 Heart rate of the fetus 2 Blood pressure of the patient 3 Respiration rate of the patient 4 Blood sugar levels in the patient
Correct 2 Blood pressure of the patient
A patient sings, verbalizes, and coos at the baby when the baby cries. Following this, the nurse finds that the baby averts the eyes and yawns. Which of the patient's actions would make the infant become fussy again? 1 Placing the infant in the cradle 2 Continuing to coo at the infant 3 Waving her hands at the infant
Correct 2 Continuing to coo at the infant
The nurse arranges a suitable environment for a patient after childbirth. Which actions of the nurse would facilitate mutual gazing of the patient and infant? Select all that apply. 1 Encourages the patient to cuddle the infant 2 Dims the lights in the patient's room 3 Delays the instillation of antibiotic into the infant's eye 4 Positions the infant on the patient's breasts 5 Teaches the patient about kangaroo care
Correct 2 Dims the lights in the patient's room Correct 3 Delays the instillation of antibiotic into the infant's eye Correct 4 Positions the infant on the patient's breasts
A nursing student asks the nurse, "Which woman is at greatest risk of bladder distention after a normal vaginal delivery?" Which is the best response by the nurse? A woman who had: 1 A midline episiotomy 2 Epidural anesthesia 3 Intravenous fluids running during labor 4 An active labor lasting 12 hours
Correct 2 Epidural anesthesia
The nurse is caring for a pregnant patient who is receiving terbutaline (Brethine) treatment. The primary health care provider (PHP) adds nifedipine (Adalat) to the patient's prescription. How does the nurse administer nifedipine (Adalat) to the patient? 1 Infuse nifedipine (Adalat) along with terbutaline (Brethine). 2 Infuse nifedipine (Adalat) only after terbutaline (Brethine) is stopped. 3 Provide a glass full of orange juice before administering nifedipine (Adalat). 4 Provide the patient with calcium supplements before administering nifedipine (Adalat)
Correct 2 Infuse nifedipine (Adalat) only after terbutaline (Brethine) is stopped.
A pregnant patient experienced preterm labor at 30 weeks' gestation. Upon assessing the patient, the nurse finds that the newborn is at risk of having cerebral palsy. Which medication administration should the nurse perform to prevent cerebral palsy in the newborn? 1 Calcium gluconate to the pregnant patient 2 Magnesium sulfate to the pregnant patient 3 Glucocorticoid drugs to the pregnant patient 4 Antibiotic medications to the pregnant patient
Correct 2 Magnesium sulfate to the pregnant patient
Which description of postpartum restoration or healing times is accurate? 1 The cervix shortens, becomes firm, and returns to form within a month postpartum. 2 Rugae reappear within 3 to 4 weeks. 3 Most episiotomies heal within a week. 4 Hemorrhoids usually decrease in size within 2 weeks of childbirth.
Correct 2 Rugae reappear within 3 to 4 weeks.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? Select all that apply. 1 Fetal heart rate of 150 beats/minute 2 The cervix is effacing and dilated to 2 cm. 3 Fetal fibronectin is present in vaginal secretions. 4 Irregular, mild uterine contractions are occurring every 12 to 15 minutes. 5 Estriol is found in maternal saliva
Correct 2 The cervix is effacing and dilated to 2 cm. Correct 5 Estriol is found in maternal saliva
Four days after delivery, the mother reports feeling restless, sad, and unable to sleep. What response should the nurse give to the patient? 1 "These negative feelings will go away within 10 days." 2 "Restrict the number of visitors you have each day." 3 "Practice some relaxing techniques." 4 "Let the family take care of the baby more.
Correct 3 "Practice some relaxing techniques."
The nurse assesses a patient 3 days after childbirth. Which behaviors would indicate that the mother has adjusted well in the postpartum period? Select all that apply. The patient: 1 Seeks to have sexual intimacy with the partner. 2 Wants to review the birth experience. 3 Desires to take charge of the infant. 4 Is excited and talkative. 5 Handles physical discomfort and emotional changes
Correct 3 Desires to take charge of the infant. Correct 5 Handles physical discomfort and emotional changes
Which culturally appropriate beliefs should the maternity nurse use to incorporate parental-infant attachment into the plan of care? Select all that apply. 1 Encourage Vietnamese mothers to cuddle with the newborn. 2 Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake. 3 Japanese mothers rest for the first 2 months after childbirth. 4 Jordanian mothers have a 40-day lying-in after birth. 5 Asian mothers are encouraged to return to work as soon as possible
Correct 3 Japanese mothers rest for the first 2 months after childbirth. Correct 4 Jordanian mothers have a 40-day lying-in after birth.
Which measure is least effective in preventing postpartum hemorrhage? 1 Administering Methergine, 0.2 mg every 6 hours for four doses, as ordered 2 Encouraging the woman to void every 2 hours 3 Massaging the fundus every hour for the first 24 hours following birth 4 Teaching the woman the importance of rest and nutrition to enhance healing
Correct 3 Massaging the fundus every hour for the first 24 hours following birth
A lactating postpartum patient reports frequent urination. What could be the reason for increased frequency of urination in the patient? A decrease in the levels of: 1 Estrogen and aldosterone 2 Oxytocin and progesterone 3 Progesterone and estrogen 4 Human chorionic gonadotropin (hCG)
Correct 3 Progesterone and estrogen
Excessive blood loss after childbirth can have several causes; however, the most common is: 1 vaginal or vulvar hematomas. 2 unrepaired lacerations of the vagina or cervix. 3 failure of the uterine muscle to contract firmly. 4 retained placental fragments
Correct 3 failure of the uterine muscle to contract firmly.
With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: 1 kidney function returns to normal a few days after birth. 2 diastasis recti abdominis is a common condition that alters the voiding reflex. 3 fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. 4 with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth
Correct 3 fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium.
The nurse is assisting a pregnant patient who is in labor. The nurse finds that the umbilical cord is protruding out from the vagina. With a gloved hand, the nurse attempts to put the umbilical cord into the vagina. The nurse continues to monitor the fetal heart rate, administers oxygen therapy to the patient, and increases the drip rate of the intravenous (IV) fluid. Which nursing action can lead to fetal and maternal complications? 1 Increasing the drip rate of the IV fluid 2 Monitoring fetal heart rate continuously 3 Administering oxygen therapy to the patient 4 Attempting to place the umbilical cord back
Correct 4 Attempting to place the umbilical cord back
While assessing a postpartum patient 24 hours after delivery, the nurse checks the lochia and finds that the patient is free of infection. Which observation related to the lochia led the nurse to make such a conclusion? 1 Dark red with a foul odor 2 Yellowish white with a fleshy odor 3 Yellowish white with a foul odor 4 Dark red with a fleshy odor
Correct 4 Dark red with a fleshy odor
The nurse is caring for a 32-year-old pregnant patient who had an onset of labor during 40 weeks' gestation. Following the labor, the nurse finds that the newborn has a low birth weight (LBW). What explanation will the nurse give to the patient as to the etiology of the newborn's LBW? 1 Preterm labor 2 Maternal age 3 Diabetic condition of the patient 4 Intrauterine growth restriction (IUGR)
Correct 4 Intrauterine growth restriction (IUGR)
During the active phase of labor, the nurse prepares for the insertion of an intrauterine pressure catheter (IUPC) to a pregnant patient. What patient clinical presentation would be the reason for this intervention? 1 Amniotic fluid of 300 mL 2 Cervical dilation of 6 cm 3 Complete deprivation of sleep in the patient 4 Reduced uterine contractions (UCs)
Correct 4 Reduced uterine contractions (UCs)
The nurse is preparing to administer terbutaline (Brethine) to a pregnant patient who is in preterm labor. What questions should the nurse ask the patient before drug administration to promote drug safety? Select all that apply. 1 "Do you ever have migraine headaches?" 2 "Do you have pregnancy-induced diabetes?" 3 "Do you suffer from nausea and vomiting?" 4 "Do you suffer from any cardiac disease?" 5 "Do you experience urinary frequency?
correct 1 "Do you ever have migraine headaches?" 2 "Do you have pregnancy-induced diabetes?" 4 "Do you suffer from any cardiac disease?"
The nurse observes that a pregnant patient who is taking terbutaline (Brethine) treatment has a heart rate of 135 beats/min. Which medication administration does the nurse expect the primary health care provider (PHP) to order? 1 Intravenous (I.V.) propranolol (Inderal) 2 1 g I.V. calcium gluconate 3 Oral dose of 20 mg of nifedipine (Adalat) 4 500 mg of I.V. calcium chloride for 30 minutes
correct 1 Intravenous (I.V.) propranolol (Inderal)
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? 1 Placing the woman in the knee-chest position. 2 Covering the cord in a sterile towel saturated with warm normal saline. 3 Preparing the woman for a cesarean birth. 4 Starting oxygen by face mask.
correct 1 Placing the woman in the knee-chest position.
While caring for a patient who is treated with terbutaline (Brethine), the nurse tries to reduce pressure on the patient's cervix to prevent preterm labor. Which nursing action would be most relevant? 1 Suggesting that the patient lie on her side 2 Infusing Ringer's lactate solution intravenously 3 Increasing the terbutaline (Brethine) concentration 4 Encouraging drinking a full glass of water periodically
correct 1 Suggesting that the patient lie on her side
Which technique is least effective for the woman with persistent occipito posterior position? 1 Squat 2 Lie supine and relax 3 Sit or kneel, leaning forward with support 4 Rock the pelvis back and forth while on hands and knees
correct 2 Lie supine and relax
During the assessment of a pregnant patient, the nurse finds that the patient has a compressed umbilical cord. What instruction does the nurse expect to receive from the obstetrician? 1 Provide a glass of orange juice to the patient. 2 Suggest that the patient lie in the lateral position. 3 Administer Ringer's lactate solution into the uterus. 4 Infuse magnesium sulfate (Epsom salt) into the patient's uterus.
correct 3 Administer Ringer's lactate solution into the uterus.
The nurse hears the fetal heart tones by placing a fetoscope above the umbilicus of a pregnant patient. What would the nurse infer from this assessment? 1 The head of the fetus will be observed initially during birth. 2 The patient cannot be administered oxytocin (Pitocin) during labor. 3 The patient cannot be administered terbutaline (Brethine) during labor. 4 The lower extremities of the fetus will be observed initially during birth
correct 4 The lower extremities of the fetus will be observed initially during birth
A pregnant patient is administered misoprostol (Cytotec) to induce labor. After 8 hours of drug administration, the patient develops diarrhea and vomiting. What does the nurse do to alleviate the symptoms? 1 Administer terbutaline (Brethine). 2 Administer oxytocin (Pitocin) infusion. 3 Give a magnesium containing antacid. 4 Increase the time between doses
correct 1 Administer terbutaline (Brethine).
The nurse is caring for a pregnant patient who has been prescribed terbutaline (Brethine) to relax the uterus. Following the assessment, the nurse informs the primary health care provider (PHP) that it is not safe to administer terbutaline (Brethine) to the patient. Which patient condition leads the nurse to such a conclusion? 1 Blood pressure of 80/60 mm Hg 2 Short episode of hyperglycemia 3 Irregular episodes of dysrhythmias 4 Heart rate of less than 120 beats/min
correct 1 Blood pressure of 80/60 mm Hg
