Maternity
Which nursing action takes priority during the admission process to the birthing unit? 1. Auscultating the fetal heart 2.Obtaining an obstetric history 3. Determining when the last meal was eaten 4. Ascertaining whether the membranes have ruptured
1 Determining fetal well-being takes priority over all other measures. If the fetal heart rate is absent or persistently decelerating, immediate intervention is required. Although obtaining an obstetric history, determining when the client had her last meal, and ascertaining whether the membranes have ruptured are equally important, the determination of fetal well-being takes priority.
Which is the focus of nursing care for a client in the transition phase of the first stage of labor? 1.Decreasing intravenous fluid intake 2.Helping the client maintain control 3.Reducing the client's discomfort with medications 4.Having the client use simple breathing patterns during contractions
1. Assisting the client in maintaining control is the most difficult part of labor. The client needs encouragement and support to cope. Intravenous fluids may need to be increased because of the increase in metabolism. Medication at this time will depress the newborn and is contraindicated. Breathing patterns at this time should be complex and require a high level of concentration to distract the client.
Where on the maternal abdomen would the nurse place the fetal heart transducer when the fetus is in the left sacrum anterior position? 1. Left lower quadrant 2. Left upper quadrant 3 Right upper quadrant 4 Midline lower quadrant
2 The left sacrum anterior position indicates that the fetus is in a breech presentation and the head is in the fundus; fetal heart sounds are best heard in the left upper quadrant. Fetal heart sounds will be in the left lower quadrant if the fetus is in the left occiput anterior position. Fetal heart sounds will be in the right upper quadrant if the fetus is in the right sacrum anterior position. The fetal heart sounds will not be heard in the midline part of a lower quadrant in a single-fetus pregnancy.
A client who is 29 weeks pregnant has uterine contractions. Which medication prescription would the nurse anticipate administering? 1. Oxytocin 2. Dinoprostone 3. Indomethacin 4. Methylergonovine
3. Substantial uterine contractions that occur before the 37th week of pregnancy should be stopped because a premature birth increases the risk of neonatal death. Indomethacin should be given for the management of preterm labor. Oxytocin is used to induce labor. Dinoprostone is also a uterine stimulant administered via the vaginal route; it is not appropriate in this condition. Methylergonovine is indicated for postpartum uterine atony and hemorrhage.
A few hours after being admitted to the hospital with a diagnosis of inevitable abortion, a client at 16 weeks' gestation begins to experience a bearing-down sensation and suddenly expels the products of conception in the bed. Which would be the nurse's immediate action? 1. Notify the primary health care provider. 2. Administer the prescribed sedative. 3. Take the client to the operating room. 4. Check the client's fundus for firmness.
4. After a spontaneous abortion the uterine fundus should be palpated for firmness, which indicates effective uterine tone. If the uterus is not firm or appears to be hypotonic, hemorrhage may occur; a soft or boggy uterus also may indicate retained placental tissue. The nurse would notify the primary health care provider if necessary after checking for fundal firmness. Administering the prescribed sedative is not the priority; the potential for hemorrhage must be monitored. Taking the client to the operating room is unnecessary; fetal and placental contents are small and expelled easily.
A laboring client is to have a pudendal block. Which effect of the pudendal block would the nurse include in the teaching plan? A. Bladder sensation may be lost. B. She will not feel an episiotomy. C. She may lose the ability to push. D. Contractions will no longer be felt.
B A pudendal block provides anesthesia to the perineum. This block affects only the perineum, not the bladder, so it does not affect bladder sensation. It does not affect muscle control so it will not affect the ability to push. It anesthetizes only the perineum, not the cervix or body of the uterus, so contractions will still be felt.
Which finding in a menopausal client's health history would prevent the health care provider from prescribing hormone replacement therapy? Select all that apply. One, some, or all responses may be 1. Smoking 2. Cirrhosis 3. Cholecystitis 4. Breast cancer 5. Deep vein thrombosis
Use of estrogens can have major side effects, especially if the client smokes. The nurse would provide information to the client about smoking cessation. Clients with cirrhosis have a decreased ability to break down medications, especially estrogen. Cholecystitis can worsen in clients taking estrogen. Clients at risk
When a client's cervix is 7 cm dilated, which other clinical manifestations does the nurse expect the client to exhibit? A. Nausea and vomiting B. Bloody and profuse show C. Inability to control her shaking legs D. Strong contractions with intervals of several minutes between
D Strong contractions with intervals of several minutes between them is a description of the contractions that occur during the active portion of the first stage of labor. Nausea and vomiting, profuse bloody show, and inability to control shaking legs all occur in the transition phase of the first stage of labor (8-10 cm cervical dilation).
Which fetal position would the nurse suspect when the fetal heartbeat is heard most distinctly in the upper left quadrant of the abdomen of the client in early labor? 1. Left sacral anterior 2. Left mentum anterior 3. Left occipital anterior 4. Left occipital transverse
1 If the fetal heartbeat is heard in the upper left quadrant, the fetus may be lying in a breech position with the body on the left side of the maternal abdomen. In the left mentum anterior position, the fetal chin is the presenting part and the fetal heart tones would be best heard in the lower quadrants of the abdomen. Left occiput anterior position means that the fetus has the head presenting with the occiput or back of the head toward the maternal left. Occiput transverse is also a cephalic presentation with the fetal head in a transverse position.
· Which fetal position would the nurse suspect when the fetal heartbeat is heard most distinctly in the upper left quadrant of the abdomen of the client in early labor? 1. Left sacral anterior 2. Left mentum anterior 3. Left occipital anterior 4. Left occipital transverse
1 If the fetal heartbeat is heard in the upper left quadrant, the fetus may be lying in a breech position with the body on the left side of the maternal abdomen. In the left mentum anterior position, the fetal chin is the presenting part and the fetal heart tones would be best heard in the lower quadrants of the abdomen. Left occiput anterior position means that the fetus has the head presenting with the occiput or back of the head toward the maternal left. Occiput transverse is also a cephalic presentation with the fetal head in a transverse position.
A client in early active labor at 40 weeks' gestation reports that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. Which is the priority nursing action? 1. Assessing maternal vital signs 2. Planning for an emergency birth 3. Administering oxygen by way of nasal cannula 4. Preparing for fetal scalp blood sampling
1. A prolonged period after the rupture of membranes and fetal tachycardia indicates the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates, and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high-flow oxygen via nonrebreather if assessment of the external monitoring is not reassuring, but this is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.
Cramping and vaginal spotting occurring at 12 weeks' gestation in conjunction with a closed cervix is characteristic of which problem? A. Missed abortion B. Inevitable abortion C. Incomplete abortion D. Threatened abortion
D Because the cervix is closed, this is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion. Once the cervix is dilated abortion is inevitable. Portions of the products of conception will have to be passed for a diagnosis of incomplete abortion.
Which action would the nurse take when external fetal uterine monitoring shows fetal heart rate (FHR) decelerations in a uniform wave shape that reflects the shape of the contraction? A. Notify the health care provider of possible head compression. B. Place the client in a knee-chest position to avoid cord compression. C. Assist the client into a dorsal recumbent position to prevent compression of the vena cava. D. Continue to monitor for return of the FHR to baseline when each contraction ends.
D. Early decelerations of the FHR commonly occur with head compression during a contraction. As long as the FHR returns to baseline at the end of the contraction, no intervention is necessary, so the health care provider would not be notified. Cord compression is also common during contractions, but no intervention is needed as long as the FHR returns to baseline with the end of the contraction, so the client would not be placed in a knee-chest position. The dorsal recumbent position will increase pressure on the vena cava and is contraindicated.
A laboring client receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. Which would be the nurse's immediate action? 1. Turning the client on her side 2. Checking the vaginal area for bleeding 3. Notifying the primary health care provider 4. Checking the fetal heart rate every 3 minutes
1 Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia; it is part of the general nursing care during labor. If signs and symptoms do not abate after the client is turned on her side, the primary health care provider should be notified. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 minutes; if this monitoring is not being performed, the rate should be checked and recorded every 15 minutes.
A client is receiving an epidural anesthetic during labor. Which alteration would the nurse recognize as a side effect of the anesthetic? 1. Hypertension 2. Urine retention 3. Subnormal temperature 4. Decreased level of consciousness
2 Anesthesia blocks the sensory pathways; therefore, the mother does not sense bladder distention and may retain urine and may be unable to void. Hypotension, not hypertension, is a side effect of epidural anesthesia. An epidural anesthetic does not influence body temperature. A decreased level of consciousness occurs with general anesthesia, not epidural anesthesia; general anesthesia is used when there is an emergency.
Which answer would the nurse give to a client who asks what is the common cause of a spontaneous abortion? 1. Physical trauma 2. Unresolved stress 3. Congenital defects 4. Embryonic defects
4. Approximately 75% of all spontaneous abortions take place between 8 and 12 weeks' gestation and reveal embryonic defects. Though possible, physical trauma rarely causes an abortion. Unresolved stress is rarely associated with spontaneous abortions. Congenital defects are asymptomatic during pregnancy and do not usually cause abortion.
The nurse administers 2 serial intramuscular injections of betamethasone to a woman at 32 weeks' gestation admitted for preterm labor. The nurse explains to the client the medication is given to accomplish which purpose? A. Stop the process of labor. B. Increase placental perfusion. C. Stimulate surfactant production. D. Reduce intensity of contractions.
C Corticosteroids stimulate surfactant production; they also have been shown to reduce the incidence of intraventricular hemorrhage. Betamethasone does not affect the labor process, increase placental perfusion, or affect the intensity of contractions.
Which is the initial nursing action when a multipara requests something for pain? · 1. Examining the client's cervix for dilation and effacement · Incorrect2 Determining the client's options by assessing the prescriptions in the chart · 3 Asking her whether she prefers an epidural or something in her intravenous line · 4 Evaluating the fetal monitoring strip to determine the frequency and duration of contractions
1. Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.
Which is the priority nursing action for a client in the second stage of labor? 1. Check the fetus's position. 2. Administer medication for pain. 3. Promote effective pushing by the client. 4. Explain that breast-feeding can start right after birth.
4. Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn's respirations. Although the mother may breast-feed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant.
While assessing a client during the fourth stage of labor, the nurse notes that the perineal pad is soaked with approximately 75 mL of lochia rubra. Which nursing action is the priority? 1. Massage the uterine fundus. 2. Document the amount and type of lochia. 3. Accompany the client to the bathroom to empty her bladder. 4. Draw blood to test for hemoglobin and hematocrit levels.
1. Massage of the uterine fundus is the intervention that will most rapidly address the problem of heavy bleeding. The fourth stage of labor is defined as the hour or 2 after delivery when the tone of the uterus is reestablished as the uterus contracts again, expelling any remaining contents. These contractions are hastened by breast-feeding, which stimulates production of the hormone oxytocin. The fundus should be massaged every 15 minutes during the first hour, every 30 minutes during the next hour, and then every hour until the uterus is firm. A boggy uterus reflects uterine atony; it should be massaged until firm. Correcting the potential for excessive blood loss is priority. Documentation of lochia, determining hemoglobin and hematocrit levels, and emptying the bladder should be done in a timely manner once bleeding is controlled.
Which is the nurse's priority assessment for a client in the fourth stage of labor? 1. Degree of relaxation 2. Distention of the bladder 3. Extent of breast engorgement 4. Presence of mother-infant bonding
2 A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding, this progresses with care and responsibility.
Which fetal heart pattern indicates cord compression? 1. Smooth, flat baseline tracings of 135 beats/min 2. Abrupt decreases in fetal heart rate that are unrelated to the contractions 3.Accelerations in the fetal heart rate of 10 beats/min above baseline 4. Decelerations when a contraction begins that return to baseline when the contraction ends
2. Abrupt decreases in fetal heart rate that are unrelated to the contractions are variable decelerations that indicate cord compression. These are most common during the second stage of labor and are considered benign unless the heart rate does not recover adequately. A flat baseline reading indicates decreased variability and may have many causes, but it is not related to cord compression. Fetal heart rate
Late fetal heart rate decelerations begin to appear when a client's cervix is dilated 6 cm, and her contractions are occurring every 4 minutes and lasting 45 seconds. Which is the likely cause of these late decelerations? 1. Imminent vaginal birth 2. Uteroplacental insufficiency 3. Pattern of nonprogressive labor 4. Normal pressure on the presenting part during contractions
2. Late decelerations are indicative of uteroplacental insufficiency and, left uncorrected, lead to fetal hypoxia, fetal myocardial depression, or both. The imminence of birth cannot be determined from fetal heart rate decelerations, only from cervical dilation. Birth occurs after the cervix has dilated to 10 cm and the fetus has passed through the birth canal. Nonprogressive labor cannot be determined from fetal heart rate decelerations, only from cervical dilation. Late decelerations are not normal, are not reassuring, and must not be ignored.
Which information would the nurse include in the teaching session for a couple about the assisted reproductive technique of in vitro fertilization (IVF)? 1. The sperm will need to come from an unknown donor. 2. Supplemental progesterone is given in early pregnancy. 3. The fertilized ova are implanted in the woman's fallopian tube. 4. After implantation, a sign that pregnancy has occurred is an absence of a menstrual period.
2. Supplemental progesterone is given to the woman undergoing IVF to promote implantation and support the early pregnancy. The sperm can be either from the woman's partner or from a donor. The primary health care provider removes the ova by means of ultrasound-guided transvaginal retrieval and mixes them with prepared sperm. In IVF the fertilized ova are placed in the uterus, not in the fallopian tubes. Because of the supplemental progesterone, the woman will not have a menstrual period even if she is not pregnant, so the absence of menses does not mean that pregnancy has occurred
Which is the desired outcome for the intrapartum client during the third stage of labor? 1. Absence of discomfort 2. Firmly contracted uterine fundus 3. Efficient fetal heart beat-to-beat variability 4.Maternal respiratory rate within the expected range
2. The third stage of labor spans the time from the birth of the baby to the delivery of the placenta; a firmly contracted uterus is desired because it minimizes blood loss. Providing comfort is a desirable goal but is secondary to the life-threatening possibility of hemorrhage associated with a boggy uterus. Efficient fetal heart beat-to-beat variability is a concern in the first and second stages of labor; it is no longer applicable after the fetus is born. The maternal respiratory rate may vary above or below this range.
The client at 7 weeks' gestation elects to undergo an induced medical abortion. Which teaching would the nurse provide regarding use of misoprostol for medical abortion? 1. Do not use misoprostol and ibuprofen together. 2. Report any cramping. 3. Misoprostol causes the uterus to expel the products of conception. 4. Report any passage of blood clots.
3 Two medications are used successively for medical abortion. Misoprostol is the second medication and it causes the uterus to contract to expel the products of conception. Ibuprofen can be safely used with misoprostol and will help with the cramping. Both cramping and passage of blood clots are expected outcomes of misoprostol and need not be reported. The client should be educated on excessive blood loss and how to contact a health care provider if that were to occur.
A client in preterm labor has a dilated cervix, and birth appears inevitable, despite medication. Which medication prescription would the nurse anticipate preparing to administer to increase the chance of the newborn's survival? 1. Misoprostol 2. Nalbuphine HCl 3. Betamethasone 4. Carboprost tromethamine
3. Betamethasone enhances fetal lung maturity when administered before a preterm birth. Carboprost tromethamine is a prostaglandin and nalbuphine HCl is a narcotic antagonist, neither of which is appropriate for administration in this case. Misoprostol is used for labor induction.
A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable, saying repeatedly, "I can't take this a minute longer." Which is the best explanation for this behavior? 1. There was no preparation for labor. 2. She needs an analgesic for pain. 3. She is entering the transition phase of labor. 4. Hypertonic uterine contractions are developing.
3. The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.
Which assessment finding suggests that the transition phase of labor has begun? 1. The client assumes the lithotomy position. 2.The frequency of contractions decreases. 3.The client complains of back and perineal pain. 4.The client begins to perspire and has a flushed face.
4 As cervical dilation nears completion, labor is intensified, resulting in an increase in energy expenditure; this increase manifests in perspiration and a flushed face. The client is usually restless and thrashes about during transition, assuming no particular position. Pain is increased because contractions are more frequent and intense, and they last longer. Back pain usually indicates a posterior-lying position of the fetus's head. Perineal pain starts during the second stage of labor.
Which fetal heart rate pattern on a client in labor would require immediate action from the nurse? 1. Remains at 140 beats per minute during contractions 2. Uniformly drops to 120 beats per minute with each contraction 3. Fluctuates from 130 to 140 beats per minute unrelated to contractions 4. Repeatedly drops abruptly to 90 beats per minute unrelated to contractions
4 This fetal heart rate change is known as variable-type decelerations. This is indicative of umbilical cord compression that, if left uncorrected, may lead to fetal compromise; interventions are directed at improving umbilical circulation. A fetal heart rate that remains at 140 beats per minute during contractions is not an unusual finding and does not require nursing intervention. Uniform drops to 120 beats per minute during contractions are recurrent early decelerations, a result of fetal head compression during a contraction. They are a benign reflex response requiring no immediate intervention. Fluctuation from 130 to 140 beats per minute unrelated to contractions is an expected variation of the fetal heart rate reflecting a well-oxygenated fetal nervous system.
The nurse at the fertility clinic is counseling a couple about the tests that will be necessary to determine the cause of their infertility. Which test will most likely be used in the initial evaluation of the woman's organs of reproduction? 1. Biopsy 2. Cystogram 3. Laparoscopy 4. Hysterosalpingogram
4 A hysterosalpingogram enables the examiner to visualize the uterus and fallopian tubes, which may identify abnormalities contributing to infertility. An evaluation for male factors should be done also in the early stages of testing. A biopsy is the surgical excision of tissue for diagnostic purposes. A cystogram is used to visualize the urinary bladder. A laparoscopy is a surgery allowing direct visualization of the internal reproductive organs. It may be done later in an infertility investigation, but would not be one of the initial steps of evaluation.
Which complication of pregnancy is of most concern when there is a positive contraction stress test (CST)? 1. Preeclampsia 2. Placenta previa 3. Imminent preterm birth 4. Uteroplacental insufficiency
4 A positive CST indicates a compromised fetus during contractions, which is associated with uteroplacental insufficiency. Preeclampsia does not cause a positive CST. The CST is contraindicated in women with suspected placenta previa, because the contractions can cause bleeding and may stimulate the onset of true labor. A CST is contraindicated in a woman with the potential for preterm birth or a pregnancy of less than 33 weeks' gestation because contractions may stimulate true labor.
A client at 31 weeks' gestation is admitted in preterm labor. Which class of medications would the nurse anticipate providing education for? 1. An oxytocic 2.An analgesic 3. A corticosteroid 4.A beta-adrenergic
4. Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex. Analgesics do not halt preterm labor. Corticosteroids do not halt labor; they are used during preterm labor to accelerate fetal lung maturity when birth is likely to occur within 24 to 48 hours.
A 25-year-old woman on estrogen therapy has a history of smoking. Which complication would the nurse anticipate in the client? 1. Osteoporosis 2. Hypermenorrhea 3. Endometrial cancer 4. Pulmonary embolism
4. Estrogen therapy increases the risk of pulmonary embolism in clients who have a history of smoking because the medication affects blood circulation and hemostasis. Osteoporosis may be caused by reduced bone density observed in postmenopausal woman. Hypermenorrhea (excessive menstrual bleeding) is treated with estrogen therapy. Endometrial cancer is a complication of estrogen therapy seen in postmenopausal woman.
Which medication would the nurse anticipate administering to stop or slow preterm labor? 1. Misoprostol 2. Prostaglandin F 3. Methylergonovine 4. Magnesium sulfate
4. Magnesium sulfate is used to stop or slow preterm labor and relax the uterus. Misoprostol, prostaglandin F, and methylergonovine cause the uterus to contract and decrease bleeding in the postpartum client.
A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. Which instruction would the nurse provide to the client in this situation? 1. Pant while pushing gently. 2. Breathe with her mouth closed. 3. Hold her breath while bearing down. 4. Pant while resisting the urge to bear down.
4. Panting prevents the mother from putting pressure on the fetal head by pushing. The nurse applies gentle pressure against the fetus's head as it emerges to prevent a precipitous birth, which could result in central nervous system injury to the fetus and vaginal lacerations in the mother. It is impossible to pant and push at the same time. Breathing with the mouth closed promotes the bearing-down reflex. Bearing down during the birth is unsafe because both fetus and mother could be injured.
A client in active labor is admitted to the birthing room. A vaginal examination reveals that her cervix is dilated 6 to 7 cm. In light of this finding, which would the nurse expect? 1. The client may experience nausea and vomiting. 2. The client's bloody show will become more profuse. 3. The client will experience uncontrollable shaking of her legs. 4. The client's contractions will become longer and more frequent.
4. The nurse should expect the client's contractions to become longer and more frequent as labor progresses through the active portion of the first stage of labor. Nausea and vomiting occur in the transition phase of the first stage of labor. More profuse bloody show and uncontrollable shaking of the legs occur in the transition phase of the first stage of labor.
Which nursing intervention would be indicated in the care of a client in the first stage of labor with the fetal heart rate baseline that was in the 150s and is now in the 130s with variability present? 1. Administering oxygen 2. Notifying the primary health care provider 3. Changing the client's position 4. Continuing to monitor the client
4. This is an expected occurrence caused by the interplay of the sympathetic and parasympathetic nervous systems. A fetal heart rate of 150 and 130 are both normal. Because this is an expected response, there is no need to administer oxygen, notify the primary health care provider, or change the client's position.
A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks' gestation. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing? A. Missed B. Complete C. Inevitable D. Threatened
C An open cervical os with heavy bleeding and tissue present indicates that a spontaneous abortion is inevitable. In a missed abortion, the fetus has died but the products of conception are retained in the uterus for several weeks. There may be no bleeding or cramping, and the os is closed. In a complete abortion, all fetal tissue has already exited the uterus and the cervix is closed; however, there may be slight bleeding. Symptoms of a threatened abortion include spotting and a closed cervical os. There may also be mild cramping.
After a client gives birth, which physiological occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled? A. Relaxation of the uterus B. Descent of the uterus in the abdomen C. Appearance of a sudden gush of blood D. Retraction of the umbilical cord into the vagina
C When the placenta separates from the uterine wall, it tears blood vessels, resulting in a gush of blood from the vagina. The uterus should become firm when the placenta begins to separate. The fundus rises in the abdomen when the placenta separates. The cord does not retract into the vagina; in fact, the reverse occurs: As the placenta separates it descends into the vaginal introitus, after which the umbilical cord appears longer and protrudes from the vagina.
In which location would the Doppler ultrasound transducer be placed to best auscultate fetal heart tones when the fetus is in the right occiput posterior (ROP) position? A. Above the umbilicus in the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin
C Fetal heart tones are best auscultated through the fetal back. In this case the presenting part is in the ROP position; the back is below the umbilicus and on the right side. Above the umbilicus in the midline is the placement that should be used when the fetus is lying in the midline in a breech position. Placement above the umbilicus on the left side is appropriate when the fetus is in the left sacrum anterior position. Placement below the umbilicus near the left groin is appropriate when the fetus is in the left occiput anterior or left occiput posterior position.
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. Which finding would the nurse expect when inspecting the perineum? A. Small tears B. Greenish-yellow amniotic fluid C. Enlarging area of caput with each contraction D. An increasing amount of amniotic fluid with each contraction
C The client should be pushing with each contraction; with the head at +3 station, each push will bring more of the caput into view at the vaginal opening. It is too early for the perineum to be stretched to the point of tearing. Greenish-yellow amniotic fluid indicates meconium staining, which is not an expected finding and may indicate that the fetus is at risk. There is a decreased, not an increased, amount of amniotic fluid at the end of labor.
