maternity/peds FINAL

14) The nurse encounters a woman giving birth at the local shopping mall. What should the nurse do first? 1. Visualize the perineum. 2. Apply counterpressure to the perineum. 3. Ask a bystander for a dry piece of clothing. 4. Determine if the membranes have ruptured.

Answer: 1 Explanation: 1. Inspecting the perineum is the only method of determining whether the client is going to give birth imminently. This is the top priority. 2. This is appropriate if the presenting part is crowning. Counterpressure to the perineum helps prevent perineal lacerations. 3. Prior to birth, some dry cloth object should be obtained to dry the infant and prevent neonatal hypothermia. 4. This is less important than knowing whether the baby is coming at this time.

19) The spouse is concerned that the client in labor will be hungry since the last time any food was eaten was several hours ago. What should the nurse explain as effects of the labor process on the client's gastrointestinal system? Select all that apply. 1. Reduced gastric motility 2. Increased gastric volume 3. Increased gastric motility 4. Reduced absorption of food 5. Prolonged gastric emptying time

Answer: 1, 2, 4, 5 Explanation: 1. During labor gastric motility is reduced. 2. During labor gastric volume remains increased regardless of the time of the last meal. 3. Gastric motility is decreased, not increased. 4. During labor absorption of solid food is reduced. 5. During labor gastric emptying time is prolonged.

17) The nurse is caring for a high-risk client in the second stage of labor. After which actions should the nurse assess the fetal heart rate? Select all that apply. 1. Vaginal examination 2. Urinary catheterization 3. Ingestion of clear liquids 4. Administration of pain medication 5. Change in oxytocin administration

Answer: 1, 2, 4, 5 Explanation: 1. For the high-risk client in the second stage of labor fetal heart rate should be assessed after a vaginal examination. 2. For the high-risk client in the second stage of labor fetal heart rate should be assessed after urinary catheterization. 3. The client in labor will be kept at nothing by mouth status. 4. For the high-risk client in the second stage of labor fetal heart rate should be assessed after administration of pain medication. 5. For the high-risk client in the second stage of labor fetal heart rate should be assessed after a change in oxytocin administration.

14) During an antenatal examination the nurse becomes concerned that the client is at high risk. What findings did the nurse use to make this clinical determination? Select all that apply. 1. Smokes one half pack per day of cigarettes 2. Employer provides maternal leave of absence 3. Is estranged from family and the baby's father 4. Loss of 3 lb since last examination 1 month ago 5. Treated for a sexually transmitted infection (STI) 2 months ago

Answer: 1, 3, 4, 5 Explanation: 1. Smoking while pregnant increases this client's risk during pregnancy. 2. Having an employer that provides maternal leave of absence would not increase this client's risks during pregnancy. 3. Lack of social support systems increases this client's risk during pregnancy. 4. A weight loss could indicate an eating disorder, which would make this client a high risk. 5. STIs increase this client's risk during pregnancy.

8) During the fourth stage of labor, the client's blood pressure (BP) is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What should the nurse do? 1. Massage the fundus. 2. Continue to monitor. 3. Turn the client onto her left side. 4. Place the bed in Trendelenburg position.

Answer: 2 Explanation: 1. The uterus should be midline and firm; massage is not necessary. 2. The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in BP and a slightly increased pulse. 3. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. 4. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.

16) A client in labor is having a pudendal block. For which adverse effects should the nurse assess this client? Select all that apply. 1. Infection 2. Spinal headache 3. Perforated rectum 4. Sciatic nerve trauma 5. Broad ligament hematoma

Answer: 3, 4, 5 Explanation: 1. An infection is not associated with a pudendal block. 2. A spinal headache is not associated with a pudendal block. 3. Disadvantages of the pudendal block include possible perforation of the rectum. 4. Disadvantages of the pudendal block include possible trauma to the sciatic nerve. 5. Disadvantages of the pudendal block include possible broad ligament hematoma.

14) A pregnant client expresses a desire to use the Lamaze method for the upcoming birth of her child. What should the nurse explain as elements of this birthing process? Select all that apply. 1. Guided imagery 2. Sensory memory 3. Dissociative relaxation 4. Controlled muscle relaxation 5. Differentiated breathing patterns

Answer: 3, 4, 5 Explanation: 1. Guided imagery is not a technique within the Lamaze method of childbirth. 2. Sensory memory is a technique within the Kitzinger method of childbirth. 3. Dissociative relaxation is used to promote birth as a normal process in the Lamaze method of childbirth. 4. Controlled muscle relaxation is used to promote birth as a normal process in the Lamaze method of childbirth. 5. Specified breathing patterns are used to promote birth as a normal process in the Lamaze method of childbirth.

20) A client's fetal heart rate tracing has a consistent late deceleration pattern. What actions should the nurse take at this time? Select all that apply. 1. Prepare for cesarean birth. 2. Increase intravenous fluids. 3. Monitor maternal blood pressure. 4. Position client on the left side. 5. Apply oxygen 7 to 10 L via face mask.

Answer: 3, 4, 5 Explanation: 1. Preparing for cesarean birth would be an action for late decelerations with tachycardia or decreasing variability. 2. Increasing intravenous fluids would be an action for late decelerations with tachycardia or decreasing variability. 3. Nursing actions for a late deceleration pattern include monitoring maternal blood pressure. 4. Nursing actions for a late deceleration pattern include positioning the client on the left side. 5. Nursing actions for a late deceleration pattern include applying oxygen 7 to 10 L via face mask. Page Ref: 356

2) A client states that her water broke 2 hours ago. What findings should the nurse identify as indications of normal labor? Select all that apply. 1. Protein of +1 in urine 2. Maternal pulse of 160 3. Blood pressure of 120/80 4. Odorless, clear fluid on underwear 5. Fetal heart rate (FHR) of 130 with average variability

Answer: 3, 4, 5 Explanation: 1. Proteinuria of +1 or more could be a sign of preeclampsia. 2. A pulse of 60 to 100 is a normal indication. 3. Maternal vital sign of blood pressure below 120/80 is a normal indication. 4. Fluid clear and without odor is a normal indication. 5. FHR 120 to 160 with variability is a normal indication.

7. A nurse is auscultating the heart rate of a fetus in a cephalic presentation. In which location would the nurse hear the heart rate most clearly? a. The lower quadrant of the maternal abdomen b. Level of the maternal umbilicus c. The upper quadrant of the maternal abdomen d. Above the apex of the fetal heart

Answer: a. The lower quadrant of the maternal abdomen Feedback: The lower quadrant of the maternal abdomen is where the nurse should hear the fetal heart rate (FHR) in a cephalic presentation. Hearing the FHR at the level of the maternal umbilicus is expected of the fetus in a transverse presentation. Hearing the FHR in the upper quadrant of the maternal abdomen is appropriate for a breech presentation. FHR is heard most clearly along the back of the fetus, not at the apex of the fetal heart.

11. When an infant is placed on the mother's abdomen, he is not moving his extremities, although they are slightly flexed. The hands and feet are blue. He cries momentarily, but is making good respiratory effort with no use of accessory muscles. He grimaces and sticks out his tongue when the nurse-midwife wipes his face. She states the cord pulse is 130. What is this baby's 1-minute Apgar score? a. 5 b. 7 c. 9 d. 10

Answer: b. 7 Feedback: This baby should be assigned 2 points for heart rate, 2 points for respirations, 1 point for color, 1 point for tone, and 1 point for reflexes.

12. A healthy, pregnant woman asks the nurse about the best way to monitor her baby's status when she is in labor. The nurse knows that continuous electronic fetal monitoring: a. Has been proven to improve outcomes for the newborn. b. Can be done via telemetry to allow ambulation. c. Is superior to intermittent auscultation. d. Is not evidence-based and should never be done.

Answer: b. Can be done via telemetry to allow ambulation. Feedback: Many facilities have wireless systems for continuous external electronic fetal monitoring that allow freedom of movement for the mother. Continuous monitoring has not been shown to result in overall improvement in neonatal outcomes. It is not superior to intermittent auscultation in low-risk labors. Though there is no strong evidence in favor of continuous monitoring in low-risk situations. When intermittent auscultation reveals FHR decelerations, it may be helpful for assessing variability and the precise timing of decelerations in relation to contractions.

12. When the presenting part is the fetal head, which cardinal movement occurs when resistance from the pelvic structures during contractions causes the fetal chin to be tucked onto the chest and the spine to curve ventrally? a. Descent b. Flexion c. Internal rotation d. Restitution

Answer: b. Flexion Feedback: Flexion occurs when resistance from the structures of the pelvis and genital tract flexes the fetal neck so that the chin touches the chest, the spine curves ventrally, and the vertex presents. Descent is the progressive movement of the fetus toward the vaginal introitus. Internal rotation is the alignment of the fetal head with the anteroposterior diameters of each plane of the pelvis as it descends. Restitution is the realignment of the fetal head with the shoulders after the head is born.

6. A nurse is planning to perform Leopold's maneuvers on a laboring client. What should be the nurse's initial action? a. Position the client in a supine position. b. Have the client void. c. Wash hands in warm water. d. Apply sterile lubricant to the abdomen.

Answer: b. Have the client void. Feedback: Having the client void before performing Leopold's maneuvers provides for improved comfort during the evaluation for the laboring client. Positioning the client on her back puts her in the correct position, but this is not the initial action. The examiner's hands should be warm, but this is not the initial action. Applying sterile lubricant to the abdomen is not part of the procedure.

2. A prenatal client is receiving home care for severe hyperemesis gravidarum. If the client does not respond to standard treatment, the nurse will anticipate adding which of the following therapies on an outpatient basis? a. Total parenteral nutrition b. IV fluids c. Low-fat soft diet d. Complex carbohydrates with limited liquids

Answer: b. IV fluids Feedback: Intravenous fluids may be ordered on an outpatient basis. Total parenteral nutrition would be started only if the client were unresponsive to IV hydration. Low-fat soft diet and complex carbohydrates with limited liquids are progressive diets after the client is stabilized for hyperemesis gravidarum.

6. A Hmong client has just given birth to a 6-pound baby girl. What culturally sensitive nursing action is appropriate at this time? a. Comment on the daintiness of her baby girl. b. Encourage the client to eat cold foods and drink cold fluids. c. Offer the mother a soft-boiled egg to eat. d. Assist the mother in bathing the baby.

Answer: c. Offer the mother a soft-boiled egg to eat. Feedback: Offering the mother a soft-boiled egg to eat is the culturally sensitive nursing action appropriate for the postpartum Hmong client. Commenting on the daintiness of her baby girl and assisting the mother in bathing the baby are not the cultural preference. Warm foods are preferred by this culture at this time, so offering cold foods would not be appropriate.

4. The nurse is evaluating an intrapartum client's lab results. Which laboratory finding should the nurse report to the physician or nurse-midwife? a. Hematocrit: 45% b. Leukocyte count: 19,000/mm c. Platelets: 120,000/mm d. White blood count: 11,000/mm

Answer: c. Platelets: 120,000/mm Feedback: The platelets (120,000/mm) should be reported as abnormally low, also called thrombocytopenia (normal: 250-500/000/mm). The hematocrit, leukocyte count, and white blood count are within normal limits for a laboring woman.

2. A client at 39 weeks' gestation calls the clinic nurse to report increasing pelvic pressure, increased energy, and vaginal secretions. The nurse would correctly interpret these as signs and symptoms of: a. A vaginal infection. b. Impending labor. c. A urinary tract infection. d. Rupture of membranes.

Answer: b. Impending labor. Feedback: Pelvic pressure, diarrhea, and vaginal secretions are symptoms of impending labor. Vaginal infection may be recognized by an odor to the vaginal secretions, along with back or abdominal pain and fever. Urinary tract infection will present with a strong odor to the urine, along with pain and/or burning upon urination with possible fever. Although rupture of membranes precedes labor in 12% of cases, it likely would be accompanied by the expulsion of large amounts of amniotic fluid.

2. A nurse is caring for a laboring client who just received systemic medication for labor pain. Which fetal heart rate pattern would require further action by the nurse? a. Increased fetal heart rate (FHR) variability and early decelerations b. Moderate variability is present. c. Occasional variable decelerations d. Minimal FHR variability and late decelerations

Answer: d. Decreased FHR variability and late decelerations Feedback: The FHR pattern showing decreased FHR variability and late decelerations would alert the nurse to a serious problem. Increased fetal heart rate (FHR) variability and early decelerations are not an alarming pattern. Short-term variability is a normal finding.

4. Butorphanol tartrate (Stadol) has been ordered for pain for a laboring client. What part of the medical record should the nurse review prior to administering the medication? a. Surgical history b. Labor course in prior pregnancies c. Allergies d. Psychiatric history

Answer: c. Assess for allergies. Feedback: Prior to administering butorphanol tartrate (Stadol) for pain, the nurse should assess for allergies. Monitoring fetal heart rate, assessing cervical dilation, and monitoring maternal vital signs are appropriate interventions, but not as the initial action.

5. The nurse is administering Benadryl per standing order to treat which commonly occurring side effect during epidural infusion? a. Pruritus b. Hypotension c. Nausea and vomiting d. General sedation

Answer: c. Assess for allergies. Feedback: Prior to administering butorphanol tartrate (Stadol) for pain, the nurse should assess for allergies. Monitoring fetal heart rate, assessing cervical dilation, and monitoring maternal vital signs are appropriate interventions, but not as the initial action.

8. A laboring client asks the nurse how often she is having contractions. Which method of measuring the interval between contractions will enable the nurse to give an accurate answer to client's question? a. Determine the interval between the acme of one contraction and the acme of the next. b. Determine the interval between the end of one contraction and the beginning of the next. c. Determine the interval between the contractions that are strong to palpation. d. Determine the interval between the beginning of one contraction and the beginning of the next.

Answer: d. Determine the interval between the beginning of one contraction and the beginning of the next. Feedback: Measuring the time from the beginning of one contraction to the beginning of the next contraction is the standard method for describing and documenting the frequency of contractions.

8. Immediately after a cesarean section birth, the anesthesiologist plans to inject a narcotic into the epidural space to provide analgesia for approximately 24 hours. Which opioid should the nurse anticipate that the physician would use? a. Naloxone (Narcan) b. Nalbuphine hydrochloride (Nubain) c. Butorphanol tartrate (Stadol) d. Duramorph

Answer: d. Duramorph Feedback: Duramorph, a form of morphine sulfate, usually is injected into the epidural space after a cesarean section birth to ease the postoperative pain for up to 24 hours. Narcan is an opiate antagonist used to reverse mild respiratory depression, sedation, and hypotension following small doses of opiates. Nubain and Stadol are narcotic agonists, but are not used in conjunction with an epidural.

7. A client presents to the primary healthcare provider's office with complaints of right-sided abdominal pain, dizziness, and vaginal bleeding. A pelvic exam determines the client to be at 10 weeks' gestation with adnexal tenderness. What diagnosis should the nurse suspect? a. Threatened abortion b. Appendicitis c. Cholelithiasis d. Ectopic pregnancy

Answer: d. Ectopic pregnancy Feedback: A client with an ectopic pregnancy would present to the physician's office with complaints of one-sided abdominal pain, dizziness, and vaginal bleeding, and would have adnexal tenderness on exam. Clients with a threatened abortion would have complaints of unexplained bleeding, cramping, or backache. A pelvic exam would reveal a closed cervix. Clients with appendicitis would have complaints of lower right-sided tenderness, low-grade fever, nausea, and often vomiting. Clients with cholelithiasis would have complaints of epigastric distress, such as fullness or distention, with vague pain in the right upper quadrant of the abdomen.

10. A low-risk client's vaginal exam reveals that her cervix is dilated to 8 cm with 75% effacement. How frequently should the nurse assess this client's vital signs? a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. Every 30 minutes

Answer: d. Every 30 minutes Feedback: The client is in the transition phase of the first stage of labor. The nurse should assess vital signs every 30 minutes. More frequent assessment of vital signs is appropriate during the second and third stages and following anesthesia.

11) Which maternal-child client should the nurse see first? 1. Blood type B, Rh-positive 2. Blood type O, Rh-negative 3. Direct Coombs test positive 4. Indirect Coombs test negative

4. Indirect Coombs test negative Answer: 3 Explanation: 1. This client's blood type creates no problems. 2. This client is Rh-negative, but there is no indication that the alloimmunization has occurred. 3. A direct Coombs test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and the baby is making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia. 4. An indirect Coombs test looks for Rh antibodies in the maternal serum; a negative result indicates the client has not been alloimmunized. Page Ref: 315

7) Which pattern, if seen on an electronic fetal monitoring strip, should the nurse explain to a client in labor as being a change in the baseline fetal heart rate? 1. Tachycardia 2. Acceleration 3. Late deceleration 4. Sinusoidal pattern

Answer: 1 Explanation: 1. Bradycardia and tachycardia are changes in the fetal heart rate baseline. 2. Accelerations are periodic changes of the fetal heart rate. 3. Late decelerations are periodic changes of the fetal heart rate. 4. A sinusoidal pattern is a periodic change of the fetal heart rate.

13) The nurse is observing a student provide care to a client who is in early labor. Which student actions should be corrected? 1. Applying a fetal heart monitor followed by an explanation of the reason for its use 2. Upon entering the room, speaking with the client prior to looking at the fetal heart monitor 3. Using layman's terms to provide the client with an explanation of the reason for electronic fetal monitoring 4. Incorporating cues that arise from intuition or from observations of the client and family as opposed to focusing on the fetal heart monitor

Answer: 1 Explanation: 1. Before using the electronic fetal monitor, the nurse needs to fully explain to the client the reason for its use and the information that it can provide. 2. The nurse can acknowledge the client's need to be the central focus by always speaking to and looking at the woman when entering the room, before looking at the monitor. 3. The technical language of electronic fetal monitoring and other procedures may act as a barrier, isolating the client and emphasizing her experience. 4. To prevent dehumanization of the nurse-client relationship, the nurse should incorporate cues that may arise from intuition or from observations of or interactions with the client and family, as opposed to focusing only upon objective monitor-based data.

1) The nurse is supervising care in the emergency department. Which situation requires immediate intervention? 1. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20. 2. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports the presence of fetal movement. 3. Spotting of pinkish brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour. 4. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer solution running at 125 mL/hour.

Answer: 1 Explanation: 1. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this situation. Since there is no information given that the client has an IV started, this client is the least stable, and therefore the highest priority. 2. Occasional spotting can occur. The presence of normal vital signs and usual fetal movements reduces this client's risk of needing immediate intervention. 3. Bleeding in the first trimester can be indicative of the beginning of spontaneous abortion or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring and will determine care. Because this client is very early in the pregnancy and only experiencing spotting, it is not appropriate to have an IV at this time. 4. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the client's vascular volume.

3) The client in labor arrives at the birthing unit with her partner. Which step of the admission process should be completed first? 1. Welcoming the couple 2. The sterile vaginal examination 3. Auscultation of the fetal heart rate 4. Checking for ruptured membranes

Answer: 1 Explanation: 1. Establishing rapport will decrease anxiety of the couple and facilitate a more pleasant birth experience. 2. The sterile vaginal examination should be performed after rapport has been established and maternal vital signs have been assessed. 3. Welcoming the couple occurs before any physical examination is performed. 4. Although assessing for intact or ruptured membranes is a part of the admission assessment, welcoming the couple is more important upon arrival.

6) A client scheduled for elective cesarean birth in 4 hours asks for a sip of coffee with creamer. How should the nurse respond? 1. "You can drink black coffee." 2. "You may have coffee with creamer." 3. "You are only allowed to drink water right now." 4. "Since you are having surgery today, you're not allowed to have anything to eat or drink."

Answer: 1 Explanation: 1. Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration. 2. Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration. While black coffee is considered a clear liquid, adding creamer would be contraindicated. 3. Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration. Black coffee is considered to be a clear liquid. 4. Avoiding both liquids and solids during labor, which was once standard practice, is no longer so because evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth.

10) The blood pressure of a client receiving continuous epidural anesthesia for labor has changed from 132/78 mmHg to 78/42 mmHg. What action should the nurse perform first? 1. Administer oxygen. 2. Administer ephedrine 5 to 10 mg intravenously. 3. Verify the client is positioned to promote left uterine displacement. 4. Increase the flow rate of infusion of intravenous crystalloid solution.

Answer: 1 Explanation: 1. If hypotension occurs secondary to epidural anesthesia, the nurse should apply oxygen via face mask first. 2. The nurse should notify the anesthesiologist for treatment orders before administering ephedrine. 3. Verification of body position is not identified as a step in the treatment of acute hypotension with an epidural infusion. 4. Administering a bolus of crystalloid fluid occurs after oxygen is applied to the client.

11) The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first? 1. Facilitate a maternal left lateral position. 2. Alert the healthcare provider of the fetal status. 3. Decrease the rate of infusion of intravenous fluids. 4. Administer oxygen to the client at 4 L per minute via nasal cannula.

Answer: 1 Explanation: 1. In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow. 2. While the attending healthcare provider should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct client care. Initially, the mother should be placed in the left lateral position. 3. Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids. 4. Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 L per minute via face mask.

12) The client in labor with meconium-stained amniotic fluid asks why the fetal monitor is necessary because the belt is uncomfortable. What should the nurse explain about monitoring? 1. "It helps us to see how the baby is tolerating labor." 2. "It can be removed, and oxygen can be given instead." 3. "It is necessary so we can see how your labor is progressing." 4. "It will prevent complications from the meconium in your fluid."

Answer: 1 Explanation: 1. Meconium-stained amniotic fluid often indicates a problem with the fetus, requiring monitoring during labor. 2. Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Fetal monitoring provides information on the status of the fetus, and it is a necessary assessment when the amniotic fluid is meconium stained. 3. The fetal monitor does not help visualize labor progress. Labor progress is assessed through the pelvic examination, checking to see if the cervix is dilating and the fetus descending into the pelvis. 4. The fetal monitor will provide information on how the baby is tolerating labor, but it does not prevent complications such as meconium aspiration syndrome.

11) The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which pain response should the nurse identify as most likely to impede progress in labor? 1. Muscle tension 2. Increased pulse 3. Increased respirations 4. Elevated blood pressure

Answer: 1 Explanation: 1. Muscle tension can impede labor progress by increased oxygen and calorie consumption and by creating a mechanical obstruction that the uterine contractions must overcome to achieve labor progress. 2. Increased pulse is a manifestation of pain, but it does not impede labor. 3. Increased respiration is a manifestation of pain, but it does not impede labor. 4. Elevated blood pressure is a manifestation of pain, but it does not impede labor.

13) The newborn of a client who received nalbuphine hydrochloride (Nubain) for pain control was born less than an hour after the medication was given and is exhibiting signs of respiratory depression. Which medication should the nurse prepare to administer to the newborn? 1. Naloxone (Narcan) 2. Fentanyl (Sublimaze) 3. Pentobarbital (Nembutal) 4. Butorphanol tartrate (Stadol)

Answer: 1 Explanation: 1. Narcan is an opiate antagonist, which would reverse the effects of the Nubain. 2. Fentanyl is a short-acting opiate that has been used during labor to relieve pain and induce sedation. It is not an opiate antagonist. 3. Pentobarbital is a sedative. It is not an opiate antagonist. 4. Butorphanol tartrate is a synthetic agonist-antagonist opioid analgesic agent. It is not an opiate antagonist.

7) The community nurse is caring for a client at 32 weeks' gestation diagnosed with preeclampsia. Which statement indicates that additional information is needed about the health problem? 1. "My urine may become darker and smaller in amount each day." 2. "Lying on my left side as much as possible is good for the baby." 3. "I should call the doctor if I develop a headache or blurred vision." 4. "Pain in the top of my abdomen is a sign my condition is worsening."

Answer: 1 Explanation: 1. Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. Oliguria should be reported to the healthcare provider. 2. Left lateral position maximizes uterine and renal blood flow and therefore is the optimal position for a client with preeclampsia. 3. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the healthcare provider. 4. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the healthcare provider.

7) A client experiencing contractions every 8 to 20 minutes that last 20 to 30 seconds requests pain medication. What should the nurse state as the effect of analgesics given at this time? 1. Prolonged labor 2. Maternal hypotension 3. Fetal respiratory depression 4. Decreased analgesic effectiveness at the end of labor

Answer: 1 Explanation: 1. Pain medication given before labor becomes established is likely to prolong the labor process. 2. Analgesics might lower the blood pressure, but this effect does not cause the contraction pattern to be altered. 3. Pain medication given before established labor does not cause fetal respiratory depression unless the client delivers within an hour of receiving the medication. This is not likely if labor is not established. 4. Medication given early in the labor process does not become less effective at the end of labor.

12) A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action? 1. Assess blood pressure and check for proteinuria. 2. Obtain a Social Services referral to discuss adoption. 3. Determine who might be the father of the baby for paternity testing. 4. Ask the client what kind of birthing experience she would like to have.

Answer: 1 Explanation: 1. Preeclampsia is more common among adolescents than in young adults, and it is potentially life threatening to both the mother and fetus. This assessment is the highest priority. 2. During labor is an inappropriate time to discuss adoption or parenting. Wait until after the birth to have this discussion when dealing with an adolescent who did not know she was pregnant prior to the onset of labor. 3. Paternity testing is a lower priority than the physiologic well-being of the client and fetus. 4. A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.

12) A healthy 18-year-old client who is at 40 weeks' gestation experiences vaginal expulsion of stringy mucus followed by blood-tinged secretions unaccompanied by discomfort or any other changes. Based upon these findings, what is most likely to occur within the next 24 to 48 hours? 1. Onset of labor 2. Cesarean section 3. Chorioamnionitis 4. Spontaneous abortion

Answer: 1 Explanation: 1. Softening and effacement of the cervix is accompanied by expulsion of the mucous plug and a small amount of blood loss from the exposed cervical capillaries. The resulting pink-tinged secretions are called bloody show. Bloody show is considered a sign that labor will begin within 24 to 48 hours. 2. The client is describing pregnancy-related changes associated with imminent onset of labor. Based upon her report, there is no indication that cesarean section will be necessary. 3. Chorioamnionitis is associated with premature rupture of amniotic membranes (PROM). Based upon the client's report, she is demonstrating mucous plug expulsion and bloody show. 4. The client is most likely demonstrating expulsion of the mucous plug and bloody show, which is considered a sign that labor will begin within 24 to 48 hours.

6) The nurse is preparing to monitor the fetal heart rate (FHR) of a pregnant client. What should the nurse explain to a nursing student as being the baseline (BL) of this heart rate? 1. "The baseline FHR excludes periods of marked variability." 2. "Normal baseline FHR ranges from 100 to 180 beats per minute." 3. "The baseline FHR should include periodic or episodic changes in FHR." 4. "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute."

Answer: 1 Explanation: 1. The baseline FHR excludes periodic or episodic changes and periods of marked variability. 2. Normal FHR (baseline rate) ranges from 110 to 160 beats per minute. 3. The baseline FHR excludes periodic or episodic changes and periods of marked variability. 4. The baseline rate is the mean FHR during a 10-minute period rounded to increments of 5 beats per minute (bpm).

4) The student nurse is performing Leopold maneuvers on a client in labor. For which action should the staff nurse intervene? 1. After determining where the back is located, the cervix is assessed. 2. The upper portion of the uterus is palpated, and then the middle section. 3. Following voiding, the client's abdomen is palpated from top to bottom. 4. The client is assisted into the supine position, and the position of the fetus is assessed.

Answer: 1 Explanation: 1. The cervical examination is not a part of Leopold maneuvers; abdominal palpation is the only technique used for the Leopold maneuver. 2. This is correct order of the first and second Leopold maneuvers. 3. The client is instructed to void prior to beginning Leopold maneuvers to facilitate comfort; Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix. 4. Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation.

9) A client in labor with cervical dilation of 9 cm is experiencing contractions every 2 minutes that are 60 to 90 seconds in duration and is complaining of excruciating rectal pressure. How should the nurse interpret this complaint? 1. The client's complaint is congruent with her current stage of labor. 2. The client's complaint may indicate the need for delivery via cesarean section. 3. Based upon the client's complaint, she is experiencing the active phase of labor. 4. The client's complaint is consistent with placental separation, which is normal for her current stage of labor.

Answer: 1 Explanation: 1. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). 2. The objective findings and client's complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). 3. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). 4. Placental separation occurs after the infant is born.

5) The nurse is explaining Leopold maneuvers to a client who is in the early stage of labor. What should the nurse explain as being the purpose of the second maneuver? 1. Locate the fetal back 2. Identify the descent of the presenting part into the pelvis 3. Determine if the pelvic inlet contains the head or buttocks 4. Determine if the fetal head or buttocks occupies the uterine fundus

Answer: 1 Explanation: 1. The second Leopold maneuver determines the location of the fetal back. 2. The fourth maneuver determines the flexion of the fetal neck and descent into the pelvis. 3. The third maneuver determines which fetal part is in the pelvic inlet. 4. The first maneuver determines what part of the fetus is in the fundus.

14) The nurse is admitting a client at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask? 1. "Do you have a safe place where you can go?" 2. "What did you do to make your spouse so angry?" 3. "How many times has this happened in the past?" 4. "Will you be pressing charges against your spouse?"

Answer: 1 Explanation: 1. This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of a repeated attack and further injury to both mother and fetus. 2. This statement is blaming and must be avoided to establish a trusting, therapeutic relationship with an abused client. 3. Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority. 4. Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more importance.

1) The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective?" 1. "A vaginal examination is performed if delivery appears to be imminent." 2. "Her prenatal record is reviewed for indications of domestic abuse." 3. "She will be positioned supine to facilitate a normal blood pressure." 4. "A urine specimen is obtained by catheter to check for protein and ketones."

Answer: 1 Explanation: 1. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal examination is performed after the vital signs are obtained. 2. Domestic abuse is not the sole reason the prenatal record is examined; any complications of pregnancy are noted. 3. Supine position predisposes the client to supine hypotension syndrome; side-lying is preferred. 4. A midstream clean-catch specimen is obtained to assess for proteinuria and ketonuria.

9) The nurse explains to a client in labor that the fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement about the most important part of fetal heart monitoring indicates that the client understands the nurse's teaching? 1. "Presence of variability" 2. "Depth of decelerations" 3. "Fetal heart rate baseline" 4. "Absence of variable decelerations"

Answer: 1 Explanation: 1. Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system. 2. The depth of decelerations does not indicate central nervous system function. 3. The fetal heart rate baseline does not indicate central nervous system function. 4. Variable decelerations indicate cord compression.

17) A client in labor received a dose of meperidine (Demerol) for pain control. Which assessment findings should the nurse suspect are adverse effects of this medication? Select all that apply. 1. Nausea 2. Pruritus 3. Sedation 4. Bradycardia 5. Hypotension

Answer: 1, 2, 3 Explanation 1. Nausea is an adverse effect of meperidine. 2. Pruritus is an adverse effect of meperidine. 3. Sedation is an adverse effect of meperidine. 4. Bradycardia is an adverse effect of fentanyl. 5. Hypotension is an adverse effect of nalbuphine hydrochloride and fentanyl.

18) A client's fetal heart rate has a sinusoidal pattern. What should the nurse consider as being the reason for this pattern? Select all that apply. 1. Fetal anemia 2. Chronic fetal bleed 3. Severe fetal hypoxia 4. Maternal hypotension 5. Umbilical cord compression

Answer: 1, 2, 3 Explanation: 1. A sinusoidal pattern is associated with fetal anemia. 2. A sinusoidal pattern is associated with chronic fetal bleed. 3. A sinusoidal pattern is associated with severe fetal hypoxia. 4. The most common cause of late decelerations is maternal hypotension. 5. Variable decelerations occur if the umbilical cord becomes compressed.

17) A client is entering the end of the second stage of labor. What should the nurse expect to assess in this client? Select all that apply. 1. Bulging perineum 2. Parting of the labia 3. Crowning of the fetus 4. Increasing bloody show 5. Increasing rectal pressure

Answer: 1, 2, 3, 4 Explanation: 1. During the end of the second stage of labor the perineum bulges as the fetal head enters the birth canal. 2. During the end of the second stage of labor the labia part as the fetal head enters the birth canal. 3. During the end of the second stage of labor crowning of the fetal head occurs, which indicates that birth is imminent. 4. During the end of the second stage of labor bloody show will increase. 5. Increasing rectal pressure occurs during the transition stage of labor.

20) A pregnant client diagnosed with Chlamydia trachomatis infection is refusing treatment. What effects on the fetus should the nurse explain might occur if treatment is waived? Select all that apply. 1. Fetal death 2. Premature labor 3. Newborn conjunctivitis 4. Chlamydial pneumonia 5. Ophthalmia neonatorum

Answer: 1, 2, 3, 4 Explanation: 1. Fetal death is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 2. Premature labor is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 3. An infant of a woman with untreated chlamydial infection may develop newborn conjunctivitis. 4. An infant of a woman with untreated chlamydial infection may develop chlamydial pneumonia. 5. Ophthalmia neonatorum is associated with gonorrhea.

18) A client in labor needs an emergency cesarean section. What should the nurse include when preparing this client for rapid induction of labor? Select all that apply. 1. Place a wedge under the right hip. 2. Insert an indwelling urinary catheter. 3. Insert an intravenous infusion catheter. 4. Provide a bolus of 1 L of intravenous fluid. 5. Preoxygenate with 3 to 5 minutes of 100% oxygen.

Answer: 1, 2, 3, 5 Explanation: 1. Before induction of anesthesia, a wedge is placed under the woman's right hip to displace the uterus and prevent vena caval compression in the supine position. 2. An indwelling bladder catheter is usually inserted before surgery for women undergoing cesarean birth. 3. Before induction of anesthesia, intravenous fluids are started so that access to the intravascular system is immediately available. 4. A bolus of intravenous fluid is provided prior to an epidural; however, it is not indicated for general anesthesia. 5. Before induction of anesthesia, the client should be preoxygenated with 3 to 5 minutes of 100% oxygen.

19) The nurse categorizes a client's fetal heart rate tracing as a level 2. What criteria were used for this categorization? Select all that apply. 1. Tachycardic baseline. 2. Decelerations lasted longer than 2 minutes. 3. Scalp stimulation did not effect acceleration. 4. Absent variability with recurrent late decelerations. 5. Variable decelerations that slowly return to baseline.

Answer: 1, 2, 3, 5 Explanation: 1. Criteria for category 2 includes a tachycardic baseline. 2. Criteria for category 2 includes prolonged decelerations lasting greater than 2 minutes. 3. Criteria for category 2 includes a lack of accelerations with scalp stimulation. 4. Criteria for category 3 includes absent variability with recurrent late decelerations. 5. Criteria for category 2 includes variable deceleration patterns that slowly return to baseline.

19) The nurse is caring for a 13-year-old client who is in labor. What actions should the nurse take to support this client's needs? Select all that apply. 1. Provide simple and concrete explanations. 2. Stay with the client during the labor process. 3. Provide soothing encouragement during the transition phase. 4. Provide positive reinforcement with a nonjudgmental manner. 5. Remain calm and provide clear directions during the second stage.

Answer: 1, 2, 3, 5 Explanation: 1. For the very young adolescent client, instructions and explanations should be simple and concrete. 2. The very young adolescent needs someone to rely on at all times during labor. 3. During the transition phase, the young teenager may become withdrawn and unable to express her need to be nurtured. Soothing encouragement helps her maintain control and meets her needs for dependence. 4. Positive reinforcement and a nonjudgmental manner are appropriate for a middle adolescent in labor. 5. During the second stage of labor it is important for the nurse to remain calm and give clear, simple directions to help the teen cope with feelings of helplessness.

19) A client is suspected of having a hydatidiform mole. What should the nurse expect to assess in this client? Select all that apply. 1. Elevated blood pressure 2. Absence of fetal heart tones 3. Frequent urination and thirst 4. Dark brown vaginal drainage 5. Larger than gestational age fundal height

Answer: 1, 2, 4, 5 Explanation: 1. Manifestations of preeclampsia are associated with a hydatidiform mole, which would include an elevated blood pressure. 2. Fetal heart sounds are absent with a hydatidiform mole because a fetus is not developing in the uterus. 3. Frequent urination and thirst are not manifestations of hydatidiform mole. 4. Dark brown vaginal discharge, similar to prune juice, occurs because of liquefaction of the uterine clot. 5. Uterine enlargement greater than expected for gestational age is a classic sign of a complete mole, which is present in about half of cases. Enlargement is due to the proliferating trophoblastic tissue and to a large amount of clotted blood.

16) A pregnant client is in a motor vehicle crash and needs surgery to repair a fractured lower leg. What special precautions will this client need during and after the surgery? Select all that apply. 1. Prepare for intubation. 2. Insert a nasogastric tube. 3. Maintain on strict bed rest. 4. Insert an indwelling urinary catheter. 5. Apply sequential compression devices (SCDs).

Answer: 1, 2, 4, 5 Explanation: 1. Pregnancy causes increased secretions of the respiratory tract and engorgement of the nasal mucous membrane, often making breathing through the nose difficult. Consequently, pregnant women often need an endotracheal tube to maintain an airway during surgery. 2. The decreased intestinal motility and delayed gastric emptying that occur in pregnancy increase the risk of vomiting when anesthetics are given and during the postoperative period. A nasogastric tube may be recommended before major surgery. 3. Exercises in bed should be encouraged along with early ambulation after surgery. 4. An indwelling urinary catheter prevents bladder distention, decreases risk of injury to the bladder, and permits monitoring of output. 5. SCDs during and after surgery help prevent venous stasis and the development of thrombophlebitis.

19) The nurse is preparing a client in labor for an emergency cesarean section. Which medication should the nurse expect to be prescribed to prevent the effects of aspirated gastric contents? Select all that apply. 1. Famotidine (Pepcid) 2. Cimetidine (Tagamet) 3. Omeprazole (Prilosec) 4. Pantoprazole (Protonix) 5. Metoclopramide (Reglan)

Answer: 1, 2, 5 Explanation: 1. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Famotidine is used to help empty gastric contents. 2. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Cimetidine is used to help empty gastric contents. 3. Omeprazole is a proton pump inhibitor and is not identified as being used before general anesthesia to help empty gastric contents. 4. Pantoprazole is a proton pump inhibitor and is not identified as being used before general anesthesia to help empty gastric contents. 5. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Metoclopramide is used to help empty gastric contents. Page Ref: 402

1. A G1P0 client calls the hospital and says to the nurse, "I think I am having labor pains. When should I come to the hospital?" The nurse correctly replies that the client should come in when her contractions are: a. 3 minutes apart for 30 minutes. b. 5 minutes apart for 1 hour. c. 5-10 minutes apart for 30 minutes. d. 10-15 minutes apart for 1 hour.

Answer: b. 5 minutes apart for 1 hour. Feedback: The nullipara client should come in when her contractions are 5 minutes apart for 1 hour. The multigravida client should come when contractions are 3 minutes apart for 30 minutes.

20) A client in the beginning stages of labor asks the nurse if the labor process will hurt the baby. What should the nurse explain to the client about the fetus's response to labor? Select all that apply. 1. The baby's heart rate will change. 2. The baby feels no pain or sensations. 3. The baby is sensitive to light and sounds. 4. The baby's oxygen level drops about 10%. 5. The blood pressure protects the baby during labor.

Answer: 1, 3, 4, 5 Explanation: 1. Early fetal heart rate decelerations can occur with intracranial pressures of 40 to 55 mmHg, as the head pushes against the cervix. 2. The fetus is experiencing labor as the woman labors. 3. Beginning at about 37 or 38 weeks' gestation, the fetus is able to experience sensations of light, sound, and touch. 4. Blood flow is decreased to the fetus at the peak of each contraction and fetal oxygen saturation drops about 10%. 5. Fetal blood pressure protects the normal fetus during the anoxic periods caused by the contracting uterus during labor.

16) The nurse is preparing to admit a pregnant client who is Muslim to the birthing center. What should the nurse keep in mind during the labor process? Select all that apply. 1. Have long-sleeved gowns available. 2. Offer warm fluids to sip during the labor process. 3. Ask the spouse for permission before examining the client. 4. Ensure female healthcare providers examine the client. 5. Provide the spouse with water to cleanse the newborn upon birth.

Answer: 1, 3, 4, 5 Explanation: 1. The woman may prefer to wear two long-sleeved gowns to enhance modesty. 2. Clients from the Laos culture usually prefer only "hot" foods and warm water to drink during labor. 3. If a specialist such as an anesthesiologist or neonatologist is needed, it is best to speak to the husband first and obtain his permission. 4. It is important for a female healthcare provider to perform examinations whenever possible. 5. After the birth, Muslim fathers clean the newborn. It is essential to have bathing supplies available for the spouse to use.

5) Which nursing action can prevent or detect common side effects of epidural anesthesia? Select all that apply. 1. Preloading the client with a rapid infusion of IV fluids 2. Continuing the client on oral fluids only to prevent hypotension 3. Assisting the client to empty the bladder before the anesthesia is started 4. Use of intermittent fetal heart rate (FHR) monitoring so the client can use the birthing ball 5. Monitoring the fetal heart rate (FHR) for late deceleration and decrease in rate

Answer: 1, 3, 5 Explanation: 1. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. 2. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. The amount of oral fluids that would be required to prevent hypotension makes this approach inappropriate for the client in labor. 3. The epidural decreases the urge to urinate. The client's bladder should be assessed frequently for distention. 4. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential. 5. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

18) The nurse suspects that a pregnant client is experiencing true labor. What did the nurse assess to make this clinical determination? Select all that apply. 1. Contractions increase in intensity. 2. Discomfort occurs in the abdomen. 3. Contractions occur at regular intervals. 4. Walking has no effect on the contractions. 5. Time between contractions gradually becomes shorter.

Answer: 1, 3, 5 Explanation: 1. In true labor contractions will increase in intensity. 2. In false labor the contractions occur in the abdomen. 3. In true labor the contractions occur at regular intervals. 4. In false labor walking has no effect on the contractions. 5. In true labor the time between contractions gradually becomes shorter.

1) The nurse is admitting a client to the labor and delivery unit. Which aspect of the history requires notifying the healthcare provider? 1. Blood pressure 120/88 2. Dark red vaginal bleeding 3. History of domestic abuse 4. Father is a carrier of sickle-cell trait

Answer: 2 Explanation: 1. Blood pressure 120/88. Although the diastolic reading is slightly elevated, this is not the top priority. 2. Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and fetus. 3. This client is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the client. 4. The infant also might have sickle trait, but sickle trait is not life-threatening at this time.

14) A client at 39 weeks' gestation is having a cesarean birth with general anesthesia. Which potential challenge is most relevant to the anesthesia care of this client? 1. Broad ligament hematoma 2. Difficulty with maternal intubation 3. Hypotension due to the intense blockade of sympathetic fibers 4. Fetal depression that is inversely proportional to maternal anesthetic depth and duration

Answer: 2 Explanation: 1. Broad ligament hematoma is a complication associated with pudendal blockade. 2. Difficulty with maternal intubation is a primary challenge of general anesthesia care for pregnant clients. 3. Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of sympathetic fibers that results in a high incidence of hypotension. 4. Fetal depression associated with general anesthesia is directly proportional to maternal anesthetic depth and duration.

2) The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed? 1. "When you check my cervix, you will find out how thinned out it is." 2. "After you assess my pelvis, you will be able to tell when I will deliver." 3. "You are going to do a vaginal examination to see how far dilated my cervix is." 4. "The reason for a pelvic examination is to determine how low in the pelvis my baby is."

Answer: 2 Explanation: 1. Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic examination assessment. 2. An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic examination, no information is obtained about the contractions. The nurse will not have enough information following the cervical examination to estimate time of birth. 3. Cervical dilation is one aspect of the pelvic examination assessment. 4. Determining the station of the presenting part is one aspect of the pelvic examination assessment.

3) The nurse has presented a teaching session on pain relief options to a prenatal class. Which client statement indicates that additional teaching is needed? 1. "An epidural can be continuous or one dose." 2. "General anesthesia is usually recommended for a cesarean section." 3. "Narcotics can be given through a client's epidural infusion catheter." 4. "A pudendal block usually works well to control pain during episiotomy repair."

Answer: 2 Explanation: 1. Epidural anesthesia can be administered in a single dose or via continuous infusion. 2. Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice indicated in the management of clients undergoing cesarean section. 3. To provide analgesia for approximately 24 hours after the birth, the analgesia provider may inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the epidural space immediately after the birth. 4. A pudendal block technique is used in the second stage of labor for the provision of perineal anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy repair. Page Ref: 394

12) Which situation in the high-risk antepartal unit requires immediate intervention? 1. Fetal monitoring is being performed on a client in her third trimester who is scheduled for a cholecystectomy tomorrow. 2. A third-trimester client pregnant with twins who required an appendectomy yesterday is positioned in a supine position. 3. Oxygen is being administered at 2 L via nasal cannula to a client in her third trimester who underwent a urolithotomy today. 4. The client in her third trimester who returned from bowel resection surgery has a nasogastric tube attached to intermittent suction.

Answer: 2 Explanation: 1. Fetal monitoring prior to, during, and after surgery on pregnant clients is important to assess the fetal condition. 2. A client undergoing surgery in the third trimester should be positioned in a left lateral position or with a hip wedge placed under the right hip. Being supine will cause vena cava syndrome and hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger uterus and heavier uterine contents, makes vena cava syndrome more problematic. 3. Oxygen is required during and after surgery during pregnancy to maintain adequate fetal oxygenation. 4. Due to the decreased peristalsis of pregnancy, pregnant clients who undergo abdominal surgery are at risk for vomiting. A nasogastric tube is placed to prevent vomiting.

11) A client in labor is concerned about needing a cesarean section and being asleep during the birth of her baby. Which nursing response is most appropriate? 1. "Your anesthesia provider will require that you go to sleep for surgery." 2. "If a cesarean section is needed, that does not necessarily mean you will need to go to sleep for surgery." 3. "We will do our best to make sure you deliver vaginally, so you do not need to have a cesarean section." 4. "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly."

Answer: 2 Explanation: 1. General anesthesia may be needed for cesarean birth and for surgical intervention with some complications. In modern obstetrics, spinal anesthesia is often administered for delivery via cesarean section. 2. While general anesthesia may be needed for cesarean birth and for surgical intervention with some complications, in modern obstetrics, general anesthesia is not used for all obstetric births. 3. Reassuring the client in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section. 4. Reassuring the client in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section.

4) The nurse is preparing teaching on maternal-fetal ABO incompatibility for antepartum clients. Which statement should the nurse include in the teaching information? 1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. 3. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction between the antigen sites on the maternal red blood cells (RBCs). 4. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type.

Answer: 2 Explanation: 1. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 3. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal red blood cells (RBCs). 4. Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type.

4) An expectant father has been at the bedside of his laboring partner for more than 12 hours. What would be an appropriate nursing intervention? 1. Insist that he leave the room for at least the next hour. 2. Offer to remain with his partner while he takes a break. 3. Suggest that the client's mother might be of more help. 4. Tell him he is not being as effective as he was and that he needs to let someone else take over.

Answer: 2 Explanation: 1. Insisting that the father leave does not reassure him about the care the woman will receive in his absence. 2. Support persons frequently are reluctant to leave the laboring woman to take care of their own needs. Offering to stay with the woman so that he can take a break reassures him that his partner will be well cared for in his absence. 3. Suggesting that the client's mother take his place does not reassure him about the care the woman will receive in his absence. 4. Telling him that he is ineffective does not reassure him about the care the woman will receive in his absence.

11) Upon delivery of the newborn, which action most promotes parental attachment? 1. Placing the newborn under the radiant warmer 2. Placing the newborn on the maternal abdomen 3. Taking the newborn to the nursery for the initial assessment 4. Allowing the mother a chance to rest immediately after delivery

Answer: 2 Explanation: 1. Removing the baby from the mother does not promote interaction. 2. Placing the baby on the maternal abdomen promotes attachment and bonding and gives the mother a chance to interact with her baby immediately. 3. Removing the baby from the mother does not promote interaction. 4. Removing the baby from the mother does not promote interaction.

13) What should be the nurse's priority when caring for an adolescent in labor? 1. Support persons 2. Developmental level 3. Cultural background 4. Plans for keeping the infant

Answer: 2 Explanation: 1. Support persons are important to planning anyone's care. 2. Knowing the adolescent's level of development is important because cognitive development is incomplete, which will affect the birthing experience. 3. Cultural background is important to planning anyone's care. 4. Before considering this area, it is important to identify the adolescent's level of development so that a plan of care is consistent with the adolescent's abilities.

3) The nurse is preparing to assess the fetus of a laboring client. Which should the nurse perform first? 1. Place the client into a left lateral position. 2. Perform the Leopold maneuver to determine fetal position. 3. Dry the maternal abdomen before using the Doppler. 4. Count the fetal heart rate for 30 seconds and multiply by 2.

Answer: 2 Explanation: 1. The fetal heart tone assessment should be performed while the client is either supine with a lateral tilt or while in left lateral position. 2. Leopold maneuvers are performed first to determine where to listen for fetal heart tones. This is the first step so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided. 3. Prior to using the Doppler device, a water-based gel is applied to the skin. 4. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold maneuvers to determine fetal position so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided.

4) The primiparous client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? 1. "You should not work so much at this point in pregnancy." 2. "Your body may be telling you it is going into labor soon." 3. "If the bladder pressure continues, come in to the clinic tomorrow." 4. "What you are describing is not commonly experienced in the last weeks."

Answer: 2 Explanation: 1. There is no indication that the client should decrease her work schedule. 2. One of the premonitory signs of labor includes lightening: The baby drops lower into the pelvis, which creates increased pelvic and bladder pressure but less pressure on the diaphragm, which makes breathing easier. 3. Lightening does not indicate pathology, and therefore there is no need to come to the clinic if the symptoms continue. 4. Lightening is a common and expected finding.

8) A newly admitted client at 32 weeks' gestation is experiencing a sudden onset of intense nausea and a frontal headache for the past 2 days. The client's initial blood pressure is 158/98, and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing? 1. Ordering a low-protein diet for the client 2. Conducting a urine dipstick test to assess for proteinuria 3. Placing a wedge under the client's left hip so that she is in a right lateral tilt position 4. Administering diuretics and facilitating a dietary regimen of strict sodium restriction

Answer: 2 Explanation: 1. This client's signs and symptoms are consistent with preeclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/day) to replace protein lost in the urine. 2. This client's signs and symptoms are consistent with preeclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria. 3. This client's signs and symptoms are consistent with preeclampsia. Appropriate interventions include instituting bed rest with the client positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion. 4. This client's signs and symptoms are consistent with preeclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating preeclampsia.

10) Which client requires immediate intervention by the labor and delivery nurse? 1. Primipara in active labor with urine output of 100 mL/hour 2. Primipara that delivered 1 hour ago with white blood cells (WBCs) of 50,000 3. Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg 4. Multipara at 5 cm with a respiratory rate of 22 between contractions

Answer: 2 Explanation: 1. This is a normal urine output and requires no further intervention. 2. A white count of 25,000 to 30,000 is normal at the end of labor and during the early postpartum period. This WBC count is abnormally high and requires further assessment and provider notification. 3. The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor. 4. The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This client requires no further intervention.

8) A client in labor who is requesting an epidural asks if the baby will be harmed. How should the nurse respond? 1. "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." 2. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." 3. "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." 4. "Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems."

Answer: 2 Explanation: 1. While proficient administration and monitoring of epidural anesthesia allow for a high degree of safety with this technique, maternal hypotension associated with epidural anesthesia may produce harmful fetal effects. 2. Continuous electronic fetal monitoring to assess fetal status is indicated in the care of pregnant clients who receive epidural anesthesia and allows for a more direct assessment of fetal status than does frequent monitoring of maternal blood pressure and pulse, which is also indicated in the care of this client. 3. While frequent monitoring of maternal blood pressure and pulse is indicated in the care of a client who receives an epidural during labor, continuous electronic fetal monitoring is also indicated for assessment of fetal status and allows for a more direct fetal assessment. 4. While administration of a bolus of IV fluid is indicated in preparation for epidural placement and reduces the risk for maternal hypotension, this intervention neither guarantees the prevention of related complications nor allows for assessment of fetal status.

17) A pregnant woman is being excavated from the back seat of a motor vehicle after a crash. In which order should this victim receive emergency care? 1. Apply oxygen. 2. Establish an airway. 3. Monitor fetal activity. 4. Position on the left side. 5. Administer intravenous fluids.

Answer: 2, 1, 5, 4, 3 Explanation: 1. Applying oxygen occurs after an airway is established. 2. The first action is to establish an airway. 3. Monitoring fetal activity occurs after the victim is stabilized. 4. Positioning on the left side helps prevent hypotension. 5. Intravenous fluids are provided to prevent shock and maintain circulation.

1) The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply. 1. Multipara at 3 cm, fetus in longitudinal lie 2. Primipara at 7 cm, fetus in military attitude 3. Multipara at 6 cm, fetus at −2 station, mild contractions 4. Primipara at 5 cm, fetal presenting part is right shoulder 5. Primipara at 4 cm, fetus with macrocephaly due to hydrocephalus

Answer: 2, 3, 4, 5 Explanation: 1. Lie refers to the relationship between the cephalocaudal axis of the mother and the cephalocaudal axis of the fetal body; longitudinal lie is normal. 2. Attitude refers to the relationship of the fetal parts to one another. Military attitude is an unflexed neck; normal fetal attitude is flexion of the neck. Military attitude creates a larger diameter of the head fitting through the pelvis. This client is experiencing a problem between the maternal pelvis and the presenting part. 3. Station refers to how low in the pelvis the baby's presenting part is; −2 station is high in the pelvis. Contractions should be strong to cause fetal descent and cervical dilation. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. 4. The presenting part is the fetal part coming through the cervix. The occiput or back of the baby's head is the most common and most effective presenting part. A shoulder presentation cannot deliver vaginally and will require a cesarean birth. This client is experiencing a problem between the maternal pelvis and the presenting part. 5. Hydrocephalus can lead to macrocephaly, or an abnormally large head. Macrocephalic babies might not fit through the bony pelvis and could require birth by cesarean section. This client is experiencing a problem between the maternal pelvis and the presenting part.

6. The client asks for information about ectopic pregnancy. The nurse correctly responds by the risk for ectopic pregnancy is increased by: (Select all that apply.) a. Pelvic inflammatory disease (PID). b. Endometriosis. c. Presence of an IUD. d. In utero exposure to diethylstilbestrol (DES).

Answer: a. Pelvic inflammatory disease (PID); b. Endometriosis; c. Presence of an IUD; d. In utero exposure to diethylstilbestrol (DES). Feedback: Ectopic pregnancy may be caused by PID, endometriosis, IUD implantation, or DES exposure, as well as previous history of ectopic pregnancy and previous tubal surgery.

15) A client entering the third trimester of labor is concerned about having enough muscle strength and stamina to give birth. Which exercises should the nurse review with the client to facilitate the birthing process? Select all that apply. 1. Yoga 2. Pelvic tilt 3. Pelvic rock 4. Kegel exercises 5. McRoberts exercises

Answer: 2, 3, 4, 5 Explanation: 1. Yoga is not identified as an exercise to facilitate the birthing process. 2. Body-conditioning exercises, such as the pelvic tilt, are taught in childbirth preparation classes. 3. Body-conditioning exercises, such as the pelvic rock, are taught in childbirth preparation classes. 4. Body-conditioning exercises, such as the Kegel exercises, are taught in childbirth preparation classes. 5. Exercises aimed at adducting the legs into an extended McRoberts position help enable the woman to stretch her hamstring muscles, a task usually required during the second stage of labor.

18) The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? Select all that apply. 1. Drop in blood pressure 2. Increased bloody show 3. Bulging of the perineum 4. Subjective feeling of faintness 5. Uncontrollable urge to bear down

Answer: 2, 3, 5 Explanation: 1. A drop in blood pressure could be due to blood loss or dehydration. It is not an indication that birth is imminent. 2. Birth is imminent if the woman has increased bloody show. 3. Birth is imminent if the woman has bulging of the perineum. 4. Subjective feeling of faintness can be due to hyperventilation. The nurse needs to coach the client to slow the rate of breathing. 5. Birth is imminent if the woman has an uncontrollable urge to bear down.

7) What is the purpose for the client in labor to utilize different breathing techniques? Select all that apply. 1. Reduces pain 2. A source of relaxation 3. A source of distraction 4. Speeds up the delivery process 5. An increased ability to cope with contractions

Answer: 2, 3, 5 Explanation: 1. Breathing techniques do not provide a form of analgesia or anesthesia. 2. When used correctly, breathing techniques can increase the woman's pain threshold and permit relaxation. 3. When used correctly, breathing techniques can enhance the ability to cope with contractions. 4. Breathing techniques have no impact on the speed of the delivery process. 5. When used correctly, breathing techniques can provide a sense of control and allow the uterus to function more effectively.

15) While palpating contractions, the nurse determines that a client is in the latent phase of labor. What findings did the nurse use to make this determination? Select all that apply. 1. Contractions rated as being moderate to strong 2. Contractions rated as being mild to moderate 3. Contractions occur every 6 minutes lasting for 40 seconds 4. Contractions occur every 2 minutes lasting for 50 seconds 5. Contraction occurs every 10 minutes lasting for 30 seconds

Answer: 2, 3, 5 Explanation: 1. Contractions in the active phase are rated as being moderate to strong. 2. Contractions in the latent phase are rated as being mild to moderate. 3. In the latent phase contractions progress to occurring every 5 to 7 minutes and last for 30 to 40 seconds. 4. In the active phase contractions occur every 2 to 5 minutes and last for 40 to 60 seconds. 5. In the latent phase contractions occur every 10 to 30 minutes and last for 30 seconds.

15) Ketones are present in a urine specimen of a client in the beginning phases of labor. What should the nurse consider as the reason for this laboratory finding? Select all that apply. 1. Edema 2. Vomiting 3. Dehydration 4. Preeclampsia 5. Insulin resistance

Answer: 2, 3, 5 Explanation: 1. Elevation of the hematocrit may reveal hemoconcentration of blood, which occurs with edema. 2. Ketones in the urine can be associated with vomiting. 3. Ketones in the urine can be associated with dehydration. 4. Proteinuria of 1+ or more may be a sign of impending preeclampsia. 5. Ketones in the urine can be associated with insulin resistance. Page Ref: 368

17) A client in labor did not attend prenatal classes and is experiencing severe pain. In which breathing technique should the nurse instruct the client to help with relaxation and control? Select all that apply. 1. Kussmaul breathing 2. Abdominal breathing 3. Slow-paced breathing 4. Pant-pant-blow breathing 5. Modified-paced breathing

Answer: 2, 4 Explanation: 1. Kussmaul breathing is a pattern associated with health problems in which excessive carbon dioxide is being eliminated through the respirations. This is associated with diabetic ketoacidosis and not labor. 2. If the client has not learned a controlled breathing technique, teaching may be difficult during active labor. In this instance, the nurse can teach abdominal breathing. In abdominal breathing, the woman moves the abdominal wall upward as she inhales and downward as she exhales. This method tends to lift the abdominal wall off the contracting uterus and thus may provide some pain relief. The breathing is deep and rhythmic. 3. Slow, deep breathing or slow-paced breathing is usually taught during prenatal classes and is not appropriate to try to teach during active labor. 4. If the client has not learned a controlled breathing technique, teaching may be difficult during active labor. In this instance, the nurse can teach pant-pant-blow breathing. As transition approaches, the woman may feel the need to breathe more rapidly. To avoid breathing too rapidly, the woman can use the pant-pant-blow breathing pattern. 5. Shallow or modified-paced breathing is usually taught during prenatal classes and is not appropriate to try to teach during active labor.

6) The nurse is teaching a prenatal class. What characteristics about false labor should the nurse include? Select all that apply. 1. Increased thin vaginal secretions 2. Pain in the abdomen that does not radiate 3. Progressive cervical effacement and dilatation 4. Contractions that do not intensify while walking 5. An increase in the intensity and frequency of contractions

Answer: 2, 4 Explanation: 1. True labor results in an increase in vaginal secretions. 2. True labor results in pain beginning low in the abdomen and radiating upward or into the back. 3. True labor results in progressive dilation. 4. True labor contractions intensify while walking. 5. True labor results in increased intensity and frequency of contractions.

20) The nurse is assisting with a precipitous birth. In which order should the nurse perform the following actions after the birth of the fetal head? 1. Instruct the client to push. 2. Suction the baby's mouth, throat, and nose. 3. Exert upward traction to the fetal head to facilitate birth of the posterior shoulder. 4. Exert downward traction on the fetal head to facilitate movement of the anterior shoulder.

Answer: 2, 4, 3, 1 Explanation: 1. The nurse then instructs the woman to push gently so that the rest of the body can be born quickly. 2. Immediately after birth of the head, the nurse suctions the baby's mouth, throat, and nasal passages. 3. The nurse then exerts gentle upward traction on the fetal head to aid in the birth of the posterior shoulder. 4. The nurse then places one hand on each side of the head and exerts gentle downward traction until the anterior shoulder passes under the symphysis pubis.

16) A low-risk client is in the second stage of labor. What actions should the nurse take regarding the auscultation of this client's fetal heart rate? Select all that apply. 1. Evaluate after ambulation. 2. Assess heart sounds every 15 minutes. 3. Evaluate before the membrane rupture. 4. Evaluate before providing medications. 5. Count for 30 seconds and multiply times 2.

Answer: 2, 4, 5 Explanation: 1. Fetal heart rate should be assessed before ambulation. 2. For a low-risk client in the second stage of labor heart sounds should be assessed every 15 minutes. 3. Since membrane rupture cannot be predicted, fetal heart rate would be assessed after the rupture of these membranes. 4. Fetal heart rate should be assessed before providing medication. 5. The fetal heart rate should be assessed for 30 seconds and then multiply times 2.

5) The client in labor has moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a −2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Obtain a clean-catch urine specimen. 2. Apply an internal fetal scalp electrode. 3. Keep the client on bed rest at this time. 4. Encourage the husband to remain in the room.

Answer: 3 Explanation: 1. A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid contamination might falsely increase the protein present. Preventing cord prolapse, which is life threatening to the fetus, is a higher priority. 2. An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This client has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present. 3. Because the membranes are ruptured and the head is high in the pelvis at a −2 station, the client should be maintained on bed rest to prevent cord prolapse. 4. It is unknown from the given information whether it is culturally appropriate for the client's husband to remain in the room for the labor and birth.

9) The neonatal nurse specialist is describing neonatal care to nursing students. What statement should the specialist include when describing a proper method for preventing heat loss in the neonate? 1. "After delivery, the newborn is immediately placed in skin-to-skin contact with the mother." 2. "Immediately after delivery, the newborn is wrapped in a blanket and placed on the mother's chest." 3. "If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat." 4. "If a radiant-heated unit is used to keep the neonate warm, the neonate is dried, wrapped in a dry blanket, and placed under the radiant heat."

Answer: 3 Explanation: 1. After delivery, the newborn is dried immediately and wet blankets are removed. Warmed blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The newborn may also be placed under a radiant-heated unit. 2. After delivery, the newborn is dried immediately and wet blankets are removed. Warmed blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The newborn may also be placed under a radiant-heated unit. 3. If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat. Because radiant heat warms the outer surface of objects, a newborn wrapped in blankets will receive no benefit from radiant heat. 4. If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat. Because radiant heat warms the outer surface of objects, a newborn wrapped in blankets will receive no benefit from radiant heat.

15) A postpartum client who received spinal anesthesia for the delivery has not voided for 5 hours and is concerned about nerve damage. How should the nurse respond about this concern? 1. "Spinal anesthesia can sometimes cause nerve damage." 2. "You are probably dehydrated. Please increase your water intake." 3. "It may be several hours before you're able to control your urination." 4. "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you."

Answer: 3 Explanation: 1. Although nerve damage is a rare occurrence in relation to spinal anesthesia, there are no objective data to suggest that this woman has experienced nerve damage. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. 2. There are no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. 3. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. 4. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

10) One minute after delivery the following is assessed in a neonate: heart rate 120 beats per minute, vigorous cry, actively moving, resists attempts to straighten an arm, facial grimace with sole flicking, body pink, extremities blue. What Apgar score should the nurse assign to this infant? 1. 6 2. 7 3. 8 4. 9

Answer: 3 Explanation: 1. Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant's Apgar score is 8. 2. Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant's Apgar score is 8. 3. Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant's Apgar score is 8. 4. Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant's Apgar score is 8.

5) A client who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing? 1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM). 2. Obtain an antibody screen (indirect Coombs test) to determine whether the client has developed isoimmunity. 3 Note the potential for ABO incompatibility and plan to carefully assess the neonate for the development of hyperbilirubinemia. 4. Notify the primary care provider and document the potential need for treatment of fetal hemolytic anemia in the baby after delivery.

Answer: 3 Explanation: 1. RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood. 2. An antibody screen (indirect Coombs test) is done to determine whether an Rh-negative woman is sensitized (has developed isoimmunity) to the Rh antigen. 3. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment, however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert healthcare providers to the need for carefully assessing the newborn for the development of hyperbilirubinemia. 4. Unlike the situation with Rh incompatibility, antepartum treatment of ABO

9) A client in labor who is receiving a continuous infusion of a local anesthetic through an epidural catheter asks if ear ringing is supposed to occur. What is the most likely cause of the client's complaint? 1. Dehydration 2. Hypotension 3. Allergic reaction 4. Local anesthetic toxicity

Answer: 4 Explanation: 1. Sensation of ringing in the ears is not an allergic reaction. 2. Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing in the ears is associated with local anesthetic toxicity. 3. Sensation of ringing in the ears is not associated with hydration status. 4. Sensation of ringing in the ears is associated with local anesthetic toxicity.

7) A client whose cervix is dilated 8 cm is restless and frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the client alone so she can rest. 2. Ask the family to take a coffee and snack break. 3. Reassure the client that she will not be left alone. 4. Encourage the client to have an epidural for pain.

Answer: 3 Explanation: 1. The client is in the transitional phase of the first stage of labor and will not want to be alone. 2. The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone. 3. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time. 4. The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief.

9) The nurse receives the following report on a client who delivered 36 hours ago: para 1, rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse? 1. Administer rubella vaccine. 2. Ask if she is breast- or bottlefeeding. 3. Determine if RhoGAM has been given. 4. Discuss the discharge education with the client.

Answer: 3 Explanation: 1. The client is rubella immune and does not need the rubella vaccine. 2. This is important but is not the top priority. 3. The client is A-negative and the newborn B-positive. The client needs RhoGAM prior to discharge. Without RhoGAM, the client will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy. 4. Discharge education is always important, but in this case it is not the most important action.

13) While caring for a client in labor the nurse determines that the baby's head has internally rotated. The client's spouse asks about other positional changes that will occur during the labor and birth. How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation? 1. Expulsion, external rotation, and restitution 2. Restitution, flexion, external rotation, and expulsion 3. Extension, restitution, external rotation, and expulsion 4. Flexion, extension, restitution, external rotation, and expulsion

Answer: 3 Explanation: 1. The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion. 2. The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion. 3. The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion. 4. The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

8) Five minutes after delivery, the neonate's body is pink with blue extremities. The heart rate is 150. The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate? 1. Rescue breathing and stimulation 2. Stimulation and resuscitative efforts 3. Nasopharyngeal suctioning and blow-by oxygen 4. Oxygen via face mask and endotracheal suctioning

Answer: 3 Explanation: 1. The neonate's Apgar score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called "blow-by" oxygen). Rescue breathing and stimulation are not required. 2. The neonate's Apgar score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called "blow-by" oxygen). This newborn does not need stimulation and resuscitation. 3. The neonate's Apgar score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called "blow-by" oxygen). 4. The neonate's Apgar score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called "blow-by" oxygen). Face mask oxygen and endotracheal suctioning are not required.

2) A pregnant client at 14 weeks' gestation is diagnosed with hyperemesis gravidarum. The most recent vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Encourage clear liquids orally. 3. Give 1 L of lactated Ringer solution IV. 4. Administer 30 mL Maalox (magnesium hydroxide) orally.

Answer: 3 Explanation: 1. Weighing the client provides information on weight gain or loss, but it is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The client needs IV fluids. 2. The client needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a client with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia. 3. The vital signs indicate hypovolemia. Giving this client a liter of lactated Ringer solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down. 4. The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. The client needs IV fluids.

10) A client's amniotic fluid is meconium stained. What should the nurse do immediately? 1. Change the client's position in bed. 3. Administer oxygen at 2 L per minute. 2. Notify the healthcare provider that birth is imminent. 4. Begin continuous fetal heart rate monitoring.

Answer: 4 Explanation: 1. Changing the client's position is not indicated. 2. Meconium-stained amniotic fluid does not indicate that birth is imminent. 3. Oxygen administration is not indicated. 4. Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring.

5) A 25-year-old woman who is at 38 weeks' gestation with her first pregnancy is embarrassed because of going to the hospital 3 times in the last week for false labor. How should the nurse respond? 1. "Do not feel bad. Everyone makes mistakes sometimes." 2. "It is impossible to distinguish between false labor and true labor." 3. "We will discuss the differences between true labor and false labor so this does not happen again." 4. "It is very difficult to tell the difference between true and false labor. Please know we are here to take care of you whenever you need us."

Answer: 4 Explanation: 1. Instead of reinforcing the woman's perception of having made an error, the nurse should reassure her that her embarrassment is unwarranted. 2. While it may be difficult to subjectively distinguish between false labor and true labor, vaginal examination can be performed to determine if cervical dilatation is occurring. 3. Rather than reinforcing the woman's incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman's embarrassment. 4. Rather than reinforcing the woman's incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman's embarrassment.

2) A client in labor wants to have a medication-free birth. What should the nurse include when discussing alternatives to pain medication with this client? 1. Emphasize that no medication will be given. 2. Review that the use of medications allows for rest and less fatigue. 3. Explain that pain relief will allow a more enjoyable birth experience. 4. Summarize how maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

Answer: 4 Explanation: 1. It is important to respect the client's wishes when possible. Once the effects are explained, it is still the client's choice whether to receive medication. 2. While pain relief can allow the client to be less fatigued, it might be the view of the nurse but not the client. 3. While pain relief can lead to a more enjoyable experience, it might be the view of the nurse but not the client. 4. The decision not to medicate should be an informed one, and it is possible that the client does not know about the effects pain and stress can have on the fetus. Once the effects are explained, it is still the client's choice whether to receive medication.

12) A client in labor is being prepared for epidural anesthesia. What should the nurse expect to perform in order to prevent the most common complication associated with this anesthesia? 1. Observe fetal heart rate variability. 2. Place the client in the semi-Fowler position. 3. Teach the client appropriate breathing techniques. 4. Rapidly infuse 500 to 1000 mL of intravenous fluids.

Answer: 4 Explanation: 1. Monitoring for fetal heart rate variability will not prevent the most common complication, which is maternal hypotension. 2. Placing the client in the semi-Fowler position will not prevent the most common complication, maternal hypotension. 3. Breathing techniques will not prevent the most common complication, maternal hypotension. 4. Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage of the procedure.

15) The nurse instructs a client on the importance of reducing exposure to infections while pregnant. Which client statement indicates that teaching has been effective? 1. "My genital herpes infection will have no effect on my baby." 2. "Because I have toxoplasmosis, my baby might be born with an abnormally long body." 3. "The rubella infection I experienced in my second trimester may lead me to become deaf." 4. "My baby may develop a serious blood infection because I have group B strep in my vagina."

Answer: 4 Explanation: 1. Primary herpes simplex infection poses the greatest risk to both the mother and her infant. Primary infection has been associated with spontaneous abortion, low birth weight, and preterm birth. Transmission to the fetus almost always occurs after the membranes rupture and the virus ascends or during birth through an infected birth canal. 2. Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma, convulsions, or retinochoroiditis. 3. Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella. 4. Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are given during labor.

10) A postpartum client with blood type A, Rh-negative delivered a newborn with blood type AB, Rh-positive. Which statement indicates that teaching about this blood type inconsistency has been effective? 1. "Because my baby is Rh-positive, I do not need RhoGAM." 2. "Before my next pregnancy, I will need to have a RhoGAM shot." 3. "If my baby had the same blood type I do, it might cause complications." 4. "I need to get RhoGAM so I do not have problems with my next pregnancy."

Answer: 4 Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization. 2. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM). The injection must be given within 72 hours after delivery to prevent alloimmunization. 3. It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization. 4. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy.

4) The charge nurse is reviewing the plans of care for four clients in labor. Which care plan requires additional information before implementing? 1. Administration of a spinal anesthetic to a client who is scheduled for a vaginal delivery 2. Administration of a spinal anesthetic to a client with a history of irritable bowel syndrome (IBS) 3. Administration of epidural anesthesia to a client who is in the first stage of labor and has a shellfish allergy 4. Administration of epidural anesthesia to a client with a history of vomiting secondary to hyperemesis gravidarum

Answer: 4 Explanation: 1. Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for vaginal birth. 2. Spinal anesthesia is not contraindicated for irritable bowel syndrome (IBS). 3. A lumbar epidural relieves pain associated with the first and second stages of labor. An allergy to shellfish is not a contraindication to epidural anesthesia. 4. Contraindications to epidural anesthesia include severe hypovolemia of any etiology. The client with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia.

1) A client in labor who rates pain as 9 on a scale from 1 to 10 requests pain medication after refusing epidural anesthesia. What action should the nurse take prior to administering butorphanol tartrate (Stadol) as prescribed? 1. Offer epidural anesthesia again. 2. Administer oxygen via face mask at 6 to 10 L per minute. 3. Obtain maternal vital signs and assess the fetal heart rate (FHR). 4. Instruct on the actions and contraindications associated with the medication.

Answer: 4 Explanation: 1. The client has refused epidural anesthesia but is authorized to receive butorphanol tartrate. 2. Routine oxygen administration is not indicated for administration of butorphanol tartrate to an asymptomatic client in labor. 3. Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the client as to the actions and contraindications associated with butorphanol tartrate. 4. Prior to administering the medication, the nurse must explain the pharmacologic effects of

8) The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Determine the color of the leaking amniotic fluid. 2. Apply oxygen to the client at 2 L per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Assist the client to change from the Fowler position to the left lateral position.

Answer: 4 Explanation: 1. The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is meconium-stained or bloody. 2. Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable. 3. There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable decelerations. 4. The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the client might get the fetus off the cord and eliminate the variable decelerations.

3. A client at 30 weeks' gestation is admitted to the maternity unit with vaginal bleeding. What should be the nurse's initial action? a. Assess blood pressure and pulse. b. Count and weigh peripads. c. Observe for pallor, clammy skin, and perspiration. d. Start an intravenous infusion drip.

Answer: a. Assess blood pressure and pulse. Feedback: The nurse's initial action for a client with vaginal bleeding at 30 weeks would be to assess blood pressure and pulse. Counting and weighing peripads; observing for pallor, clammy skin, and perspiration; and starting an intravenous infusion drip are all important actions for this client; they are just not the initial action.

6) A client with preeclampsia is assessed with the following: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. Which new assessment finding indicates the client's condition is getting worse? 1. Reflexes 2+ 2. Platelet count 150,000 3. Blood pressure 158/104 4. Urinary output 20 mL/hour

Answer: 4 Explanation: 1. The reflexes are normal at 2+. 2. The platelet count is normal, though it is at the lower end. 3. The blood pressure has not had a significant rise. 4. The decrease in urine output is an indication of decrease in glomerular filtration, which indicates a loss of renal perfusion. The assessment finding most abnormal and life threatening is the urine output change.

3) The primiparous client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? 1. "Come in for an appointment today and we will check everything out." 2. "Unless you have pain with urination, we do not need to worry about it." 3. "This might indicate that the baby is no longer in a head down position." 4. "These symptoms usually mean the baby's head has descended further."

Answer: 4 Explanation: 1. There is no need for an additional appointment, as increased pelvic pressure and urinary frequency are premonitory signs of labor. 2. Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection. 3. The client is experiencing premonitory signs of labor; the fetus changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis. 4. This is the best response because it most directly addresses what the client has reported. Increased pelvic pressure and urinary frequency are premonitory signs of labor.

13) The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Clear fluid is leaking from the vagina." 3. "Client is positioned in a left lateral tilt." 4. "Entrance wound present below the umbilicus."

Answer: 4 Explanation: 1. These are normal vital signs, indicating a hemodynamically stable client. 2. Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term and would likely survive birth at this time. 3. Positioning the client in a lateral tilt position prevents vena cava syndrome. 4. Penetrating abdominal trauma has a 59% to 80% fetal injury rate. This fetus is at great risk for injury.

6) Prior to receiving lumbar epidural anesthesia, in which position should the nurse place the client in labor? 1. Lying prone with a pillow under the chest 2. On the right side in the center of the bed with the back curved 3. On the left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed with the back slightly curved and feet on a stool

Answer: 4 Explanation: 1. This position is not consistent with access to the epidural spaces. 2. Especially in pregnant women, this position is not ideal for facilitating access to the epidural space. 3. This position is not consistent with access to the epidural spaces. 4. Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the epidural spaces to be accessed more easily. Page Ref: 398

2) The primiparous client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. How should the nurse respond to this client? 1. "What did you expect? You have only had contractions for a few hours. Labor takes time." 2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." 3. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix." 4. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

Answer: 4 Explanation: 1. This reply is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a primipara averages 12 to 24 hours, the nurse must always be therapeutic in all communication. 2. The perineal body thinning primarily occurs during the second stage of labor; it is not expected now. 3. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change. 4. Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much longer than do subsequent labors and births.

3) A 28-year-old woman at 16 weeks' gestation being screened for ABO incompatibility learns that her blood contains anti-A antibodies. What should the nurse explain about this finding? 1. "You may have contracted anti-A antibodies as a result of a viral infection." 2. "It's most likely that you contracted anti-A antibodies through sexual activity." 3. "Anti-A antibodies are inherited; usually, they are genetically passed down from father to daughter." 4. "Anti-A antibodies occur naturally, as a result of exposure to foods and different infections."

Answer: 4 Explanation: 1. Women develop anti-A and anti-B antibodies as a result of exposure to the A and B antigens through infection by gram-negative bacteria and not viruses. 2. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not contracted through sexual activity. 3. Women develop anti-A and anti-B antibodies naturally as a result of exposure to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not inherited. 4. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria.

12. The nurse is present for a labor evaluation of a G2P1 at term by the family practice resident. He tells her she is 9 cm and will have her baby soon. She states "I'm really scared this one s going to come too fast. I had a lot of stitches with my first and I don't want that to happen again." What can the nurse do that will be most helpful to this client? a. Suggest pushing and birth in a side-lying position. b. Recommend an epidural to relieve the pain during the repair. c. Help her to accept whatever outcome occurs. d. Ask the resident to consider an episiotomy.

Answer: Suggest pushing and birth in a side-lying position Feedback: Side-lying positions are helpful for slowing fetal descent and facilitating perineal relaxation. An epidural does not address the mother's goal to avoid stitches. The nurse can help the mother accept the outcome of her birth but efforts at preventing an undesirable outcome are more helpful. Collaboration between the nurse and physician is appropriate, but episiotomies are not indicated for the prevention of lacerations.

1. A G1P0 client's cervix is 4 cm dilated. She tells the nurse, "I'm in pain, but I'm afraid that medication might harm my baby." Which response by the nurse is the most therapeutic regarding pain medication during labor? a. "Pain medications do affect the baby, but so do pain and stress." b. "You are correct in your belief that medication might harm your baby." c. "The doctor has ordered only a small amount, so your baby will be quite safe." d. "The new medications are so much safer than the old medications."

Answer: a. "Pain medications do affect the baby, but so do pain and stress." Feedback: "Pain medications do affect the baby, but so do pain and stress" is the best response. Pain and stress can cause changes in the mother that can reduce the oxygen supply to the baby, whereas some medications are safe for the baby while allowing the mother to be more comfortable.

7. A nurse is caring for a client during the fourth stage of labor. What are the expected assessment findings at this time? a. Decreased blood pressure and increased pulse b. Increased blood pressure and increased pulse c. Decreased blood pressure and decreased pulse d. Increased blood pressure and decreased pulse

Answer: a. Decreased blood pressure and increased pulse Feedback: Decreased blood pressure and increased pulse are the expected assessment findings during the fourth stage of labor.

9. Your client in her fourth month of her pregnancy is suspected to have an incompetent cervix. Which diagnostic measures might the nurse expect to be ordered to confirm the diagnosis? (Select all that apply.) a. Determining a history of second-trimester abortions b. Serial pelvic examinations c. Serial ultrasounds d. Determining a history of drug abuse

Answer: a. Determining a history of second-trimester abortions; b. Serial pelvic examinations; c. Serial ultrasounds Feedback: Diagnosis of incompetent cervix is determined by a history of unexplained second-trimester abortions, serial pelvic examinations, and serial ultrasound examinations, but not by determining a history of drug abuse.

7. The nurse is caring for a client in the transition phase of labor. What objective data would indicate that the client is having increased pain? a. Dilated pupils and increased blood pressure b. Muscle tension and decreased blood pressure c. Decreased respiration and increased blood pressure d. Increased pulse and decreased blood pressure

Answer: a. Dilated pupils and increased blood pressure Feedback: Dilated pupils, along with increased blood pressure, pulse, and respiration rate, indicate pain. Muscles would be tense.

8. A client at 15 weeks' gestation presents to the prenatal clinic with painless, thin, brown vaginal bleeding. Other assessment data include a hemoglobin of 10 and complaints of severe nausea and vomiting. What diagnosis should the nurse suspect? a. Hydatidiform mole b. Placenta previa c. Prolapsed cord d. Abruptio placentae

Answer: a. Hydatidiform mole Feedback: A client with a hydatidiform mole at 15 weeks' gestation presents at the prenatal clinic with "prune juice"-like vaginal bleeding, anemia, and complaints of severe nausea and vomiting. Placenta previa symptoms include painless bright red vaginal bleeding, usually in the third trimester of pregnancy. Prolapsed cord symptoms include a trickle of bright red vaginal blood and possibly a visible cord at the vaginal opening. Abruptio placentae symptoms include vaginal bleeding (bright red or dark red), abdominal pain, and uterine tenderness.

3. A nurse is caring for a laboring client who just received an epidural block. What is the major adverse effect for which the nurse should observe? a. Hypotension b. Unilateral block c. Hypertension d. Pruritus

Answer: a. Hypotension Feedback: Hypotension due to vasodilation from the initial effects of the epidural may be prevented with a preload bolus of 500 cc IV solution. Unilateral block and pruritus are less common adverse effects. Hypertension may be a complication of pregnancy-induced hypertension and oxytocin inductions.

1. The nurse assesses a laboring client whose contractions occur every 5-7 minutes and last for 30 seconds. In which phase of labor is this client most likely to be? a. Latent b. Active c. Transition d. Second

Answer: a. Latent Feedback: The latent phase of labor is when contractions occur every 5-7 minutes and last for 30 seconds. In the active phase, contractions should occur every 2-3 minutes. In the transition phase, contractions should occur every 1½-2 minutes. There is no second phase.

9. A pregnant client asks the nurse, "How will I know when I am close to starting labor?" The nurse correctly states that one possible sign of impending labor is: a. Loss of weight. b. Increase in appetite. c. Feeling of fatigue. d. Abdominal discomfort.

Answer: a. Loss of weight. Feedback: Impending labor may be indicated by a weight loss of 2.2-6.6 kg (1-3 lb) resulting from fluid loss and electrolyte shifts produced by changes in estrogen and progesterone levels. Diarrhea, indigestion, or nausea and vomiting usually occur just prior to the onset of labor. Some women report a sudden burst of energy approximately 24-48 hours before labor. Abdominal discomfort can be a sign of false labor.

4. A G4P3 client who has just entered the second stage of labor asks the nurse, "How much longer will it be before I have my baby?" What would be the best estimate that the nurse could provide? a. One hour b. Two hours c. Three hours d. Four hours

Answer: a. One hour Feedback: One hour is a reasonable estimate of time until delivery for a multipara woman in transition. Three hours or less would be a more appropriate answer for a nullipara woman.

3. A nurse is caring for a client admitted to the birthing unit with rupture of membranes for 2 hours. A pelvic exam reveals a dilatation of 4 cm, and the presenting part is not engaged. Which possible complication should the nurse anticipate? a. Prolapsed cord b. Placenta previa c. Amniotic infection d. Abruptio placentae

Answer: a. Prolapsed cord Feedback: When a pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged, the nurse should anticipate a prolapsed cord. With placenta previa, the placenta is implanted in the lower uterine segment rather than the upper portion of the uterus, and it is not a complication of ruptured membranes or cervical dilatation. Amniotic infection is a potential complication after the membranes have been ruptured for more than 12 hours, especially if uterine contractions are present. Abruptio placentae is the premature separation of a normally implanted placenta from the uterine wall, and is not a complication of ruptured or cervical dilatation.

2. A G1P0 client at 39 weeks' gestation arrives at the birthing center with irregular contractions ranging from 10 to 30 minutes apart. Assessment data reveals 1-2cm cervical dilation, membranes intact, and a thick cervix. What would be the most appropriate nursing action at this time? a. Send the client home to ambulate. b. Admit the client to the birthing center. c. Begin to hydrate the client with IV fluids. d. Monitor the client with pelvic checks every hour.

Answer: a. Send the client home to rest. Feedback: A client with contractions 10-30 minutes apart and 1-2cm cervical dilation, membranes intact, and a thick cervix is in the latent phase of early labor. Send the client home to rest and conserve her energy for active labor. The client will be admitted only when she begins active labor. Beginning to hydrate the client with IV fluids is not appropriate; there is no dehydration status or preterm labor. Monitoring the client with pelvic checks every hour is not appropriate until the client is in active labor and progress has been made.

11. A client on the postpartum unit reports a severe headache to her nurse. That client's vital signs are within normal limits and she has no history of headaches. What intervention recorded in the labor record can the nurse identify as a cause for the headache? a. Spinal block b. Narcotic administration c. IV fluid bolus d. Administration of nonsteroidal anti-inflammatory medications (NSAIDs)

Answer: a. Spinal block Feedback: Postpartum headache may result from puncturing the dura mater for a spinal block. Narcotic administration may result in sedation. An IV fluid bolus may result in bladder distension as the fluid is processed by the kidneys. It is not associated with increased headaches. NSAIDs, used correctly, improve headaches. They do not cause or exacerbate them.

11. A client whose blood type is A negative declines RhoGAM, stating "I don't believe in vaccinations." The blood type of the father of the baby is unknown. What is the nurse's best response? a. "That's fine as long as you've done your research on it." b. "Declining this is can create very serious problems in future pregnancies." c. "You have to have RhoGAM if your blood is Rh negative." d. "Consider how irresponsible it is to put your children at risk."

Answer: b. "Declining this can create very serious problems in future pregnancies." Feedback: It is the nurse's responsibility to provide accurate information and to open a dialogue for the purpose of correcting knowledge deficits. Telling the client that it is fine to decline RhoGAM confirms her mistaken beliefs. Conversely, telling the client that she has to do something or calling her irresponsible is condescending and judgmental. These approaches are likely to alienate the client and make her less receptive to teaching.

5. A laboring client in the birthing center has a hematocrit of 49. The nurse should anticipate that this finding may be related to: a. Anemia. b. Dehydration. c. Hemorrhage. d. Infection.

Answer: b. Dehydration. Feedback: Dehydration is indicated by a hematocrit of 49% resulting from hemoconcentration. Anemia and hemorrhage are indicated by low hemoglobin. Infection is indicated by a high white blood cell count.

9. A laboring client complains of numbness of nose, fingers, and toes, and spots before her eyes. What should be the initial action by the nurse? a. Implement seizure precautions. b. Encourage slow, shallow breaths. c. Administer oxygen at 5 L per minute. d. Notify the primary healthcare provider or nurse-midwife.

Answer: b. Encourage slow, shallow breaths. Feedback: Encouraging slow, shallow breaths should be the initial action by the nurse for a laboring client who complains of symptoms of hyperventilation (hypocarbia). Slow, shallow breathing will help her build up her CO2 level to balance out her oxygen levels. Implementing seizure precautions, administering oxygen, and notifying the primary healthcare provider or nurse-midwife are not appropriate nursing actions for hyperventilation.

10. The nurse is caring for a client at 37 weeks' gestation who has gestational hypertension and is in the active phase of labor. How frequently should the nurse assess the fetal heart rate? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every hour

Answer: b. Every 15 minutes Feedback: Assessing the fetal heart rate every 15 minutes is appropriate for a high-risk client in active labor. Assessing the fetal heart rate every 5 minutes is appropriate for high-risk clients in the second stage of labor; every 30 minutes is appropriate in the latent phase for high-risk clients; and every hour is appropriate in the latent phase for low-risk clients.

3. A client is admitted to the birthing center with possible rupture of membranes. What substance in the fluid could contribute to a false positive reading on nitrazine test tape? (Select all that apply.) a. Feces b. Lubricant c. Bacteria d. Meconium

Answer: b. Lubricant Feedback: Lubricant in the fluid could contribute to a false positive reading on nitrazine test tape. Feces, bacteria, or meconium in the fluid will not alter the test results.

9. The nurse is caring for primigravida who has expressed a desire for an epidural in her birth plan. What notation in the medical record may require changes to her plan? a. Gestational hypertension b. Platelet count of 90,000 per microliter c. History of cervical biopsy d. Allergy to shellfish

Answer: b. Platelet count of 90,000 per microliter Feedback: Thrombocytopenia and coagulopathies are contraindications to epidural placement. The possible side effect of blood pressure reduction may be beneficial in the setting of gestational hypertension. History of cervical biopsy has no implications for epidural placement. Allergy to shellfish may be associated with allergy to iodine, which is not used in the placement of epidurals.

12. The provider places an order for butorphanol, 2 mg IV x 1 dose. What are the most appropriate nursing actions immediately following its administration? a. Measure intake and output. b. Raise the side rails and place the call button within the client's reach. c. Evaluate the effectiveness of pain relief. d. Obtain an order for the timing of subsequent doses.

Answer: b. Raise the side rails and place the call button within the client's reach. Feedback: Butorphanol often causes sedation and may cause disorientation and dizziness. It is important for the client to call for assistance when attempting to get out of bed until these effects subside. Butorphanol does not affect urine output. It is appropriate to evaluate its effectiveness and obtain orders for subsequent doses, but these are not required immediately after administration.

11. A G4P3 at term presents to the labor and birth unit apparently in active labor. Her birth plan states she is an Orthodox Jew and that she would like to observe her religious traditions around childbirth. Her husband hugs her, states he will be in the waiting room, and leaves the client alone with the nurse. What is the most appropriate nursing response? a. Assess the client for signs of domestic abuse. b. Reassure the client that the nursing staff will be present and supportive. c. Encourage the husband to participate in the labor and birth process. d. Tell the client that most fathers are present for the birth of their children.

Answer: b. Reassure the client that the nursing staff will be present and supportive. Feedback: Some cultures, including Orthodox Judaism, do not value and may even prohibit the participation of men in labor and birth. Screening for domestic abuse should be done for all clients but following traditional cultural practices is not evidence of increased risk. Encouraging the family to act against their preferences and discussing the preferences of other families is not therapeutic or appropriate.

6. A nurse assesses a rise in the fundal height and a sudden gush of blood from the vagina of a postpartum client 5 minutes after birth. The nurse appropriately interprets these finding as: a. Immediate postpartum hemorrhage. b. Separation of the placenta. c. Late postpartum hemorrhage. d. Delivery of the placenta.

Answer: b. Separation of the placenta. Feedback: Separation of the placenta is characterized by a rise in fundal height and sudden gush of blood 5 minutes after birth. Immediate postpartum hemorrhage is not characterized by a rise in fundal height. Late postpartum hemorrhage occurs 24-48 hours or more after birth. Delivery of the placenta is characterized by a decrease in fundal height.

2. The physician orders internal fetal monitoring for a laboring client. What criterion must the client meet prior to this procedure? a. The fetal part must be engaged. b. The membranes must be ruptured. c. The cervix must be dilated to 4 cm. d. The fetus must be in an occiput-anterior position

Answer: b. The membranes must be ruptured. Feedback: The membranes must be ruptured for internal fetal monitoring to be used for a laboring client. The fetal part must be accessible by vaginal exam but does not have to be engaged. The cervix needs to be dilated at least 2 cm. Any position of the vertex is acceptable.

6. The nurse is to administer naloxone (Narcan) intravenously. Which medication order would be the most appropriate initial dose to counteract a narcotic-induced maternal respiratory depression? a. 0.125-0.25 mg b. 0.2-0.4 mg c. 0.4-2.0 mg d. 3.0-4.0 mg

Answer: c. 0.4-2.0 mg Feedback: For reversal of respiratory depression in a laboring woman, the initial recommended dosage of Narcan is 0.4-2.0 mg intravenously. Dosages of Narcan 0.125-0.25 mg and 0.2-0.4 mg are too low, whereas 3.0-4.0 mg is too high.

7. A nurse is caring for a client who received a spinal block for a cesarean birth. The client asks the nurse when she can get out of bed. The nurse's best response is: "You will need to remain in bed for at least __________." a. 1-2 hours b. 24 hours c. 6-12 hours d. 3-4 hours

Answer: c. 6-12 hours Feedback: Temporary motor paralysis of the client's legs will continue after birth. The client will remain in bed for 6-12 hours after birth.

4. Four clients are admitted to the labor and birth unit. Which client's nurse should the charge nurse avoid assigning another client so she continues to receive the most focused nursing care possible? a. A 28-year-old G1P0 with ruptured membranes and 7 cm dilation b. A 33-year-old G3P2 with intact membranes and 4 cm dilation c. A 15-year-old G1P0 with ruptured membranes and 9 cm dilation d. A 31-year-old G5P4 with intact membranes and 4 cm dilation

Answer: c. A 15-year-old G1P0 with ruptured membranes at 9 cm Feedback: All women need support during labor and birth, but an adolescent in the transition phase of her first labor is likely to have more difficulty coping and integrating her sensations than mature, multiparous women in an earlier phase of labor.

8. The nurse is caring for four laboring clients in the first stage of labor. Which client is demonstrating responses commonly seen during the latent phase? a. A client with increased fatigue, restlessness, and anxiety b. A client with increased irritability who is feeling out of control c. A client who is happy and talkative d. A client who has just delivered a healthy newborn

Answer: c. A client who is happy and talkative Feedback: A client who is happy and talkative is demonstrating responses commonly seen during the latent phase. Increased fatigue, restlessness, and anxiety are commonly seen during the active phase. Increased irritability and feeling out of control are responses commonly seen during transition. Birth occurs at the end of the second stage of labor.

5. A nurse is at the nurse's station looking at the central monitoring display for the labor and birth unit. Which tracing should be evaluated at the bedside first? a. Fetal heart rate 140-150 bpm, moderate variability, no accelerations or decelerations b. Fetal heart rate 120-125 bpm, minimal variability, no accelerations or decelerations c. Fetal heart rate 135 bpm, minimal variability, intermittent late decelerations d. Fetal heart rate 150-160 bpm, moderate variability, intermittent variable decelerations to 110 bpm

Answer: c. Fetal heart rate 135 bpm, minimal variability, intermittent late decelerations Feedback: A tracing showing minimal variability accompanied by late decelerations is Category III and requires prompt evaluation and intervention. Moderate variability is the most important indicator of fetal well-being, so the tracings showing moderate variability and a normal baseline rate are reassuring. The tracing showing minimal variability without decelerations should be observed for their development but may represent a fetal sleep cycle

8. The fetal monitor has shown several late decelerations over the past 10 minutes. What does this pattern indicate? a. Umbilical cord compression b. Head compression c. Fetal hypoxia d. Maternal fever

Answer: c. Fetal hypoxia Feedback: A pattern of late decelerations indicates fetal hypoxia, caused primarily by uteroplacental insufficiency. Variable decelerations are caused by umbilical cord compression. Early decelerations are caused by head compression. Maternal fever may contribute to fetal tachycardia.

1. A nurse is reviewing the factors important in the process of labor. Which two pelvic types are favorable for labor and vaginal delivery? a. Gynecoid and android b. Platypelloid and anthropoid c. Gynecoid and anthropoid d. Android and platypelloid

Answer: c. Gynecoid and anthropoid Feedback: Gynecoid and anthropoid pelvis types are favorable for labor or delivery, whereas android and platypelloid pelvis types are not favorable.

1. The nurse is reviewing the lab tests of four prenatal clients. Which lab finding would support the diagnosis of hyperemesis gravidarum? a. Hypercalcemia b. Hyperkalemia c. Hypokalemia d. Hypocalcemia

Answer: c. Hypokalemia Feedback: Potassium loss (hypokalemia), not hyperkalemia, is characteristic of hyperemesis gravidarum. Neither hypercalcemia nor hypocalcemia (low calcium) is characteristic of hyperemesis gravidarum.

11. A nurse is performing intermittent auscultation in the active phase of the first stage of labor at term after a low-risk pregnancy. The fetal heart rate is 140 at 5 p.m. What would be an indication for checking it again before 5:30? a. A burst of fetal activity b. If blood-streaked mucous were noted on the peri pad c. If the mother reported a gush of fluid d. Immediately after an episode of vomiting

Answer: c. If the mother reported a gush of fluid Feedback: When monitoring fetal well-being using intermittent auscultation in a low-risk client, the fetal heart rate should be auscultated every 30 minutes in the active phase of the first stage of labor and after rupture of membranes. The fetal heart should be auscultated to assess for cord compression. Vomiting and passage of blood-streaked mucous are expected in active labor and, in themselves, have no impact on the fetus.

12. A client denies domestic violence at her first prenatal visit. What is the best plan for future screening? a. Repeat screening at the initial visit for all subsequent pregnancies. b. The requirements for screening are satisfied by this negative result. c. Repeat screening in each trimester and postpartum. d. Repeat screening annually.

Answer: c. Repeat screening in each trimester and postpartum. Feedback: It is important to screen for domestic violence at the first prenatal visit, at least every trimester thereafter, and postpartum. Violence is sometimes exacerbated by pregnancy, so the screening may become positive even if it was negative at the first visit. The client may also need time to develop trust with the healthcare team before being willing to disclose this kind of information. Never repeating the screening, or waiting a year or until the next pregnancy, may expose the client to risk that could have been avoided through counseling and assistance.

4. A client at 17 weeks' gestation is admitted to the labor and birth unit. Her chief complaint is abdominal cramping and vaginal spotting. What is the priority nursing diagnosis for this prenatal client? a. Risk for Ineffective Coping related to unknown outcome of pregnancy b. Knowledge Deficit related to management of vaginal bleeding c. Risk for Infection related to spontaneous abortion d. Impaired Physical Mobility related to continuous fetal monitoring

Answer: c. Risk for Infection related to spontaneous abortion Feedback: The priority nursing diagnosis for this prenatal client is Risk for Infection related to spontaneous abortion. Secondary diagnoses are Risk for Ineffective Coping related to unknown outcome of pregnancy, Knowledge Deficit related to unfamiliarity with loss of vaginal fluids, and Impaired Physical Mobility related to strict bedrest.

10. A prenatal nurse is assessing a client at 34 weeks' gestation who complains of vaginal irritation and thin, vaginal discharge that is "a funny color." What should be the nurse's initial action? a. Prepare for a nonstress test. b. Obtain vaginal cultures for STIs. c. Test the fluid with nitrazine paper. d. Test the urine for bacteria.

Answer: c. Test the fluid with nitrazine paper. Feedback: Testing the fluid with nitrazine paper would be the nurse's initial action, not preparing for a nonstress test or testing the urine for bacteria. Obtaining vaginal cultures for STIs is performed if further evaluation of the client is required.

3. A G3P0 client in active labor is admitted to the birthing center. Which data set should the nurse interpret as being within the normal range? a. Temperature 98.6°F and pulse 46 b. Temperature 98.4°F and blood pressure 142/90 c. Temperature 100.8°F and pulse 88 d. Temperature 99.4°F and blood pressure 130/88

Answer: d. Temperature 99.4°F and blood pressure 130/88 Feedback: During the first stage of labor, normal blood pressure is 90-140/60-90, pulse 60-90, respirations 12-20/minute, and temperature < 37.6°C (99.6°F).

5. A prenatal client at 16 weeks' gestation presents to the clinic with unexplained, bright red bleeding; cramping; and backache for the past 2 days. A pelvic exam reveals a closed cervix. What type of abortion does this indicate? a. Imminent b. Missed c. Threatened d. Incomplete

Answer: c. Threatened Feedback: A threatened abortion (miscarriage) has symptoms of vaginal bleeding and backache without cervical dilation. In an imminent abortion, the internal cervical os is dilated. Although the cervix is closed in a missed abortion, other symptoms would include a regression in breast changes and a brownish vaginal discharge. Diagnosis is made based on history, pelvic exam, and a negative pregnancy test. With an incomplete abortion, the embryo has passed out of the uterus, but the placenta remains, and the internal os is slightly dilated.

5. A laboring client complains of nausea, vomiting, and increasing rectal pressure. She states, "I can't take this anymore." The nurse correctly assesses that this client is in which phase of labor? a. Latent b. Active c. Transition d. Second stage

Answer: c. Transition Feedback: Transition is the phase of labor where clients usually complain of nausea, vomiting, and increasing rectal pressure, and state, "I can't take any more." A laboring client usually is able to cope in the latent and active phases of labor. Nausea, vomiting, and rectal pressure decrease during the second stage with the birth of the baby.

9. The nurse has auscultated a fetal heart rate of 80. What should the nurse's initial action be? a. Position the client on her left side. b. Administer oxygen at 5 L per minute. c. Notify the primary healthcare provider or nurse-midwife. d. Check the maternal pulse.

Answer: d. Check the maternal pulse. Feedback: The nurse should check the maternal pulse, because the rate of 80 could be the maternal heart rate rather than the fetal heart rate. Positioning the client on her left side, administering oxygen at 5 L per minute, and notifying the physician or nurse-midwife would be appropriate only if the rate of 80 (fetal bradycardia) had been confirmed to be the fetal heart rate.

10. The nurse is caring for a laboring client who is scheduled for an epidural block. What action by the nurse prior to the epidural placement would decrease the chance of maternal hypotension? a. Monitor maternal vital signs. b. Administer oxygen at 5 L/min. c. Reposition the client every hour. d. Infuse an IV bolus of 500-1000 mL of normal saline.

Answer: d. Infuse an IV bolus of 500-1000 mL of normal saline. Feedback: Giving a 500mL fluid bolus prior to the epidural will reduce the chance of maternal hypotension. Monitoring maternal vital signs would not decrease the chance of maternal hypotension. Administering O2 at 5 L/min is appropriate after hypotension has developed, to ensure proper oxygenation of the fetus, but it does not impact hypotension. Repositioning the client every hour is a comfort measure that is appropriate throughout the administration of the block.

10. A laboring client complains to the nurse about intense pain located primarily in her back. Which fetal position should the nurse expect to see written on the client's chart? a. Right-occiput-anterior (ROA) b. Left-mentum-transverse (LMT) c. Right-sacrum-anterior (RSA) d. Left-occiput-posterior (LOP)

Answer: d. Left-occiput-posterior (LOP) Feedback: Either occiput-posterior (LOP or ROP) position of the fetus would cause a woman to complain of intense backache, as the fetal head presents a larger diameter in the posterior position. The anterior positions and transverse positions do not place additional pressure on the sacrum and are not associated with intense backache.