NSG 1600 Maternity

Which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beats over the baseline rate of 135 beats per minute that lasts 15 seconds? 1 An acceleration 2 An early increase 3 A sonographic motion 4 A tachycardic heart rate

1 An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats per minute.

Which recommendation would the nurse make to a pregnant client who sits almost continuously during her working hours? 1 "Try to walk around every few hours during the workday." 2 "Ask for time in the morning and afternoon to elevate your legs." 3 "Tell your boss that you won't be able to work beyond the second trimester." 4 "Ask for time in the morning and afternoon so you can go get something to eat."

1 Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly those in the popliteal spaces, and may diminish venous return. Walking causes the leg muscles to contract and applies gentle pressure to the veins, thereby promoting venous return. Walking around several times each morning and afternoon will improve circulation; the legs may be elevated while the client is sitting at her desk. If the client is feeling well, there are no contraindications to working throughout her pregnancy. Adequate nourishment can be obtained during mealtimes; the client does not require extra nutrition breaks.

During a nonstress test, the baseline fetal heart rate of 130 to 140 beats per minute rises to 160 twice and 157 once during a 20-minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take? 1 Discontinue the test because the pattern is within the normal range. 2 Encourage the client to drink more fluids to decrease fetal heart rate. 3 Notify the primary health care provider and prepare for an emergency birth. 4 Record this nonreassuring pattern and continue the test for further evaluation.

1 The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.

Which information would tell the nurse if a woman at 40 weeks' gestation having contractions is in true labor? 1 The cervix dilates and becomes effaced in true labor. 2 Bloody show is the first sign of true labor. 3 The membranes rupture at the beginning of true labor. 4 Fetal movements lessen and become weaker in true labor

1 The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.

While caring for a client during labor, which would the nurse remember about the second stage of labor? 1 It ends at the time of birth. 2 It ends as the placenta is expelled. 3 It begins with the transition phase of labor. 4 It begins with the onset of strong contractions.

1 The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.

Morning sickness generally disappears by the end of which month? 1 Fifth month 2 Third month 3 Fourth month 4 Second month

2 Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin but has usually diminished by the fifth month.

Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation? 1 Clear, dark amber colored, and containing shreds of mucus 2 Straw colored, clear, and containing little white specks 3 Milky, greenish yellow, and containing shreds of mucus 4 Greenish yellow, cloudy, and containing little white specks

2 By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." Which action would the nurse take to confirm that the membranes have ruptured? 1 Take the client's oral temperature. 2 Test the leaking fluid with nitrazine paper. 3 Obtain a clean-catch urine specimen. 4 Inspect the perineum for leaking fluid.

2 Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the initial assessment. Although this may be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic fluid. Inspecting the perineum for leaking fluid will not confirm rupture of the membranes.

A prenatal client's vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client's clinical record? 1 Hegar 2 Goodell 3 Chadwick 4 Braxton-Hicks

3 A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton-Hicks contractions, can be felt through the abdominal wall.

Which condition is detected by an alpha-fetoprotein test? 1 Kidney defects 2 Cardiac anomalies 3 Neural tube defects 4 Urinary tract anomalies

3 The alpha-fetoprotein test detects neural tube defects, Down syndrome, and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.

Which is the nurse's first action when a client in active labor starts screaming, "The baby is coming! Do something!"? 1 Notify the practitioner of the imminent birth. 2 Tell the client that it is too soon and encourage her to pant. 3 Check the perineal area for visibility of the presenting part. 4 Help the client hold her knees together and explain what to expect.

3 The first action by the nurse would be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse would remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.

In which location is the presenting part of the fetus when it is at 0 station? 1 Entering the vagina 2 Floating within the bony pelvis 3 At the level of the ischial spines 4 Above the level of the ischial spines

3 The ischial spines are used as landmarks in relation to the fetus's head because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines. When the head enters the vagina, it is below the ischial spines and its position is designated with positive numbers (+1 to +4). When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (-1 to -4).

Which instruction would the nurse include when teaching episiotomy （外阴切开术）care? 1 Rest with legs elevated at least 2 times a day. 2 Avoid stair climbing for several days after discharge. 3 Perform perineal care after toileting until healing occurs. 4 Continue sitz baths 3 times a day if they provide comfort.

3 Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.

When can a primigravida fetal heartbeat be heard for the first time? 1 A stethoscope at 4 weeks 2 A fetoscope at 10 to 12 weeks 3 Doppler ultrasound after 20 weeks 4 Doppler ultrasound at 10 to 12 weeks

4 A fetal heartbeat can be obtained at 10 to 12 weeks with electronic Doppler ultrasound. The heartbeat cannot be obtained with a stethoscope, and 4 weeks is too early to hear a fetal heart. A fetoscope cannot pick up the heartbeat until the 17th week. The heart rate can be detected 8 to 10 weeks earlier than 20 weeks.

Which food contains at least 100 mcg of folate per serving? Select all that apply. One, some, or all responses may be correct. 1 Bread 2 Broccoli 3 Cooked pasta 4 Black-eyed peas 5 Ready-to-eat breakfast cereal

4, 5 Neural tube defects (NTDs), or failures in closure of the neural tube, are more common in infants of women with poor folic acid intake. Proper closure of the neural tube is required for normal formation of the spinal cord, and the neural tube begins to close within the first month of gestation, often before a person realizes she is pregnant. Therefore, all people who are capable of becoming pregnant should take 0.4 mg of folic acid every day, in addition to consuming dietary sources of folate. One-half cup of black-eyed peas contains at least 100 mcg of folate. Ready-to-eat breakfast cereal contains 200 mcg of folate. A slice of bread contains 20 mcg, not 100 mcg of folate. One-half cup of broccoli and a cup of pasta contain 50 mcg, not 100 mcg of folate. Also see the screenshot from Lowdermilk