NUR 113 test 4

1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity.

A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. The nurse must have calcium gluconate in the client's room.

A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).

C. Below the ischial spines. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: A. Not yet engaged B. Entering the pelvic inlet C. Below the ischial spines D. Visible at the vaginal opening

3. The nurse should call a code first.

A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

4. Benadryl is an antihistamine. It is the drug of choice for this client who has pruritus and a rash.

A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Zofran (ondansetron). 3. Compazine (prochlorperazine). 4. Benadryl (diphenhydramine).

1. The nurse would expect the client to be crying and sad.

A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sad. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.

3. Absent variability would be expected as a result of Stadol administration.

A client with an internal fetal monitor catheter in place has just received IV butorphanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Diminished short- and long-term variability. 4. Accelerations after contractions.

1. Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures.

A breastfeeding mother refuses to place her unclothed baby face down on her chest because "babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

3. A urinary drainage bag may be put in place by the CNA.

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. It would be appropriate for the nurse to delegate which of the following actions to the assistant? 1. Admission assessment on a newly delivered baby. 2. Patient teaching of a neonatal sponge bath. 3. Placement of a bag on a baby for urine collection. 4. Hourly neonatal blood glucose assessments.

4. It is the registered nurse's responsibility to provide discharge teaching to clients. Only the RN knows the scientific rationales as well as the knowledge of teaching-learning principles necessary to provide accurate information and answer questions appropriately.

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby.

B. Increased efficiency of contractions. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: A. Less pressure on her cervix B. Increased efficiency of contractions C. Decreased number of contractions D. The need for increased maternal blood pressure monitoring

D. Support the perineum with the hand to prevent tearing and tell the client to pant. Gentle pressure is applied to the baby's head as it emerges so it is not born too rapidly. The head is never held back, and it should be supported as it emerges so there will be no vaginal lacerations. It is impossible to push and pant at the same time.

A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: A. Transfer her immediately by stretcher to the birthing unit B. Tell her to breathe through her mouth and not to bear down C. Instruct the client to pant during contractions and to breathe through her mouth D. Support the perineum with the hand to prevent tearing and tell the client to pant

3. This action is very important. If the legs are removed from the stirrups one at a time then the woman is at high risk for back and abdominal injuries.

A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

3. The nurse would expect to see a decrease in the baseline variability.

A client, 6 cm and 80% effaced, has just received Demerol (meperidine) 50 mg IV for pain. Which of the following fetal heart changes would the nurse expect to observe on the internal fetal monitor tracing? 1. Drop in baseline heart rate. 2. Increase in number of variable decelerations. 3. Decrease in variability. 4. Rise in number of early decelerations.

2. A wedge should be placed under one side of the woman.

A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

3. Because this woman is a multipara, the position is LOA, and the station is +3, this is an accurate statement.

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

B and D. Signs and symptoms of preeclampsia include: proteinuria (>1+ dipstick urine protein or >300 mg/dL 24 hour urine protein, hypertension >140/90...two reading at least 4-6 hours apart), swelling in face, eyes, extremities, headaches, vision changes, etc.

A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the development of preeclampsia in this patient that would need to be reported to the physician? Select all that apply:* A. 1600: blood pressure 144/100, 1700: blood pressure 120/80 B. 3+ dipstick urine protein C. 1 hour glucose tolerance test 90 mg/dL D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98 E. <300 mg/dL 24-hour urine protein

3 mL/hr.

A woman, 402⁄7 weeks' gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units oxytocin (Pitocin) to be diluted in 1,000 mL D51⁄2 NS. The order reads: Administer oxytocin IV at 0.5 milliunits per min. Calculate the drip rate for the infusion pump to be programmed. Please calculate to the nearest whole number. __________ mL/hr.

4. It is appropriate to monitor the woman's labor.

A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give her oxygen. 3. Change her position. 4. Monitor her labor.

2. Effleurage is a light massage that can soothe the mother during labor.

In addition to breathing with contractions, which of the following actions can help a woman in the first stage of labor to work with her pain? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

A. The pressure in the fetal lungs is HIGH, which allows blood from the PULMONARY ARTERY to shunt into the AORTA via the DUCTUS ARTERIOSUS.

Fill in the blank: The pressure in the fetal lungs before birth is __________, which allows blood from the _____________ to shunt into the ______________ via the __________________.* A. high, pulmonary artery, aorta, ductus arteriosus B. high, pulmonary vein, aorta, ductus venosus C. low, aorta, pulmonary artery, pulmonary vein, ductus arteriosus D. low, right atrium, left atrium, foramen ovale

D. Ultrasound Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination shouldn't be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring won't detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta separation.

Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa? a. Amniocentesis b. Digital or speculum examination c. External fetal monitoring d. Ultrasound

c It is important for the nurse to stress that death from SIDS​ isn't predictable or preventable and that it​ isn't the​ parents' fault. Reassure the parents that they are not responsible for the​ infant's death. For families with multiple​ children, it may also be necessary to reassure older children that they are not in danger of SIDS. Instructing the parents about future children is not therapeutic at this time.

When communicating with the grieving family of an infant who has just died from sudden infant death syndrome​ (SIDS), which information should the nurse​ include? A. Instructing the parents to place future infants on their backs to sleep B. Stressing that nothing can be done to confirm the diagnosis C. Stressing that the death​ isn't the​ parents' fault D. Reminding the parents that they are still young and can have more children

2. Change the client's position. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.

When examining the fetal monitor strip after the rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A. Stop the oxytocin infusion B. Change the client's position C. Prepare for immediate delivery D. Take the client's blood pressure

2. This is an appropriate action.

The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug? 1. Monitor the urinary output hourly. 2. Supervise while the woman holds her newborn. 3. Position the woman slightly elevated on her left side. 4. Ask any visitors to leave the room.

b Leakage of fluid similar to a coagulation factor from a placental abruption can trigger DIC. Onset of infection and amniotic fluid embolism are not the greatest risk. Hemorrhagic shock is caused by blood​ loss, not septic shock.

The nurse is caring for a client diagnosed with placental abruption who now has disseminated intravascular coagulation​ (DIC). Which statement correctly explains why this client is at risk for​ DIC? A. Septic shock due to blood loss. B. Leaked fluid is similar to a coagulation factor. C. Amniotic fluid embolism. D. Onset of infection.

c During the second stage of labor the client requires encouragement and support. The client at a​ +5 station is an imminent delivery. Providing sips of​ water, applying extra blankets for​ warmth, and frequent perineal cleansing are not priorities at this time.

The nurse is caring for a client in the second stage of labor and at a​ +5 station. The client appears overwhelmed and is experiencing perineal burning. Which action is a priority for the nurse at this​ time? A. Providing frequent perineal cleansing B. Applying extra blankets for warmth C. Offering encouragement and support D. Providing frequent sips of water

C. All the other options are INCORRECT.

Which statement is TRUE regarding abruptio placenta?* A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the cervical opening. B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical opening. C. Nursing interventions for this condition includes measuring the fundal height. D. Fetal distress is not common in this condition as it is in placenta previa.

a, b, c, e Protective behaviors for SIDS include​ supine, not​ prone, positioning. Use of a pacifier while​ sleeping, use of sleeper​ pajamas, breastfeeding, and neutral ambient temperature are all protective behavior for SIDS

The nurse is presenting on prevention of sudden infant death syndrome​ (SIDS). Which protective behavior should the nurse​ include? (Select all that​ apply.) A. Breastfeeding B. Use of sleeper pajamas C. Neutral ambient room temperature D. Prone positioning E. Use of pacifier while sleeping

3 and 4 are correct. 3. Pressure applied on the medial surface of the lower leg has been shown to lessen the pain of labor. 4. Pressure applied to the depression at the top one third of the sole of the foot has been shown to lessen the pain of labor.

The nurse is providing acupressure to provide pain relief to a woman in labor. Where is the best location for the acupressure to be applied? Select all that apply. 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. At the top one third of the sole of the foot. 5. Below the medial epicondyle of the elbow.

d The most appropriate response by the nurse is to continue monitoring the client.

The nurse providing care for a client in active labor notes a gradual decline in the fetal heart​ rate, beginning with the onset of a contraction and followed by a gradual return to baseline by the end of the contraction. Which is the most appropriate nursing​ response? A. Notifying the healthcare provider B. Administering oxygen C. Preparing for operative delivery D. Continuing monitoring

4. The baby's head is almost crowning.

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

1. It has been shown that many neonatal SIDS deaths result from a form of suffocation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Babies should be placed supine.

The nursing diagnosis—Risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? 1. Baby will be placed supine for sleep. 2. Baby will be breastfed in the side-lying position. 3. Baby will be swaddled when in the open crib. 4. Baby will be strapped when seated in a car seat.

0.25 mL

The health care practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? Calculate to the nearest hundredth. _____ mL

2. Once the cervix begins to dilate, a client is in true labor.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

1. Weight loss is a positive sign.

The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2+ proteinuria. 3. Decrease in plasma protein. 4. 3+ patellar reflexes.

C. Preeclampsia tends to occur AFTER 20 weeks gestation.

The nurse knows that preeclampsia tends to occur during what time in a pregnancy?* A. before 20 weeks B. in the third trimester and postpartum C. after 20 weeks D. in the first and second trimester

C. The blood pumped from the right ventricle contains both oxygenated and deoxygenated blood. Therefore, it is mixed.

The right ventricle pumps what type of blood up through the pulmonary artery?* A. Oxygenated B. Deoxygenated C. Mixed

D: The antidote for Magnesium Sulfate is Calcium Gluconate. The nurse should have this on hand in case Magnesium toxicity occurs.

Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication on standby?* A. Acetylcysteine B. Calcium carbonate C. Oxytocin D. Calcium gluconate

A. May lose the ability to push. A pudendal block provides anesthesia to the perineum.

A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she: A. Will not feel the episiotomy B. May lose bladder sensation C. May lose the ability to push D. Will no longer feel contractions

A. Swelling of the calf in one leg. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria

1, 5, 3, 4, 2. The correct order of the movements listed is: 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion.

A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.

a At this point in​ time, the​ nurse's best response is to honestly inform the client that he is not sure but that the healthcare provider will speak with the client about it after considering the severity of the disease for her against the risks for the baby. The nurse cannot ensure that hospitalization will increase the length of time before delivery nor can the nurse know that the baby will necessarily be delivered​ early, so this would not be the best response for the nurse to make. Telling the client that the primary concern is getting her to the hospital dismisses the current client concerns as not important and would not be the best response to the question.

A pregnant client at 28 weeks of gestation is diagnosed with preeclampsia after reporting persistent headache and blurry vision. The​ client's blood pressure is​ 162/112 mmHg and hospitalization is recommended. The client asks the nurse if the baby will have to be delivered early. Which response best addresses the​ client's question? A. ​"I am not sure right now. The healthcare provider will speak with you about it after considering the severity of the disease for you against the risks for your​ baby." B. ​"Given that you have such severe symptoms at only 28 weeks of​ gestation, it is highly likely that your baby will be delivered​ prematurely." C. ​"Placing you in the hospital will help to ensure that we can increase the length of time before you​ deliver, allowing the baby to​ mature." D. ​"I know that you are​ frightened, but right now what is most important is getting you to the hospital. You can discuss these concerns with your healthcare provider​ later."

A and B. The nurse would want to place the patient on their side (preferably the left-side...not supine) to help prevent the tongue from obstructing the airway, preventing aspiration, and improving blood flow to the placenta. In addition, the nurse would NOT want to restrain the patient, which can cause injury. Option C, D, and E are steps the nurse would want to take.

A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure?* A. Placing the patient in a supine position B. Holding down the patient's head to prevent injury C. Staying with the patient and activating the emergency response team D. Timing the seizure E. Providing 8 to 10 L of oxygen

2. Vistaril can be used as an analgesic potentiator.

A G1 P0, 8 cm dilated, is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with an analgesic-potentiating medication. Which of the following medications would the nurse expect to be ordered as the analgesic-potentiating medication? 1. Seconal (secobarbital). 2. Vistaril (hydroxyzine). 3. Benadryl (diphenhydramine). 4. Tylenol (acetaminophen).

1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit.

A client has been transferred to the post-anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

a, c, d, e Manifestations of DIC include​ bleeding, clotting,​ petechiae, and joint pain.​ Hypotension, not​ hypertension, is also a manifestation of DIC

A client has disseminated intravascular coagulation​ (DIC). Which clinical manifestation should the nurse expect to​ observe? (Select all that​ apply.) A. Petechiae B. Hypertension C. Bleeding D. Clotting E. Joint pain

4. The fetus should be assessed for intrauterine growth restriction.

A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.

1. The nurse would expect the woman to be 2 cm dilated.

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

4. A nurse could conclude that a fetus is in the LOA when feeling small objects— the fetal arms and legs—on the right side of the uterus.

A fetus is in the LOA position in utero. Which of the following findings would the nurse observe when doing Leopold's maneuvers? 1. Hard, round object in the fundal region. 2. Flat object above the symphysis pubis. 3. Soft, round object on the left side of the uterus. 4. Small objects on the right side of the uterus.

3. This response indicates that the labor contractions are increasing in intensity.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

1. Clients with severe preeclampsia are high risk for seizure.

A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

C. The client complains of a headache and blurred vision. If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening Preeclampsia.

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? A. Blood pressure reading is at the prenatal baseline B. Urinary output has increased C. The client complains of a headache and blurred vision D. Dependent edema has resolved

3. An order to assess the woman's cervical dilation should be questioned.

A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1. Administer betamethasone (Celestone) 12 mg IM daily times 2. 2. Maintain strict bed rest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 mL/hr).

1. An order for oxytocin administration should be questioned.

A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1, 3, 4, and 5 are correct. 1. This statement is true. A birth may take place in the shower, when the mother is in a soaking tub, in a bed, or even while standing. 3. If the fetus is in the posterior or transverse position, the woman may be encouraged to push while on her hands and knees. This may enable the baby to turn into the anterior position and the delivery may soon follow. 4. Many mothers deliver in their labor beds without stirrups. Some beds transform into delivery beds and some are regular hospital beds. Still others are double or queen-sized beds so that the father and/or the delivering practitioner can also relax in the bed. When forceps or other interventions are needed for a delivery, however, stirrups may be required. 5. Midwives deliver their clients in a variety of positions, including the side-lying, squatting, and lithotomy positions, as well as when the clients are on their hands and knees.

A pregnant woman is discussing positioning and the use of leg stirrups for delivery with a labor nurse. Which of the following client responses indicates that the client understood the information? Select all that apply. 1. When the client states, "I am glad that deliveries can take place in a variety of places, including a Jacuzzi bathtub." 2. When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." 3. When the client states, "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." 4. When the client says, "During difficult deliveries it is sometimes necessary to put a woman's legs up in stirrups." 5. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

3. Because this is a normal finding, the nurse should continue to provide labor support and encouragement.

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's health care practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Continue to provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

C. Respiratory rate of 10 BPM. Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. Option A: A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Option B: Deep tendon reflexes of 2+ are normal. Option D: The fetal heart rate is WNL for a resting fetus.

A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A. Urinary output of 20 ml since the previous assessment B. Deep tendon reflexes of 2+ C. Respiratory rate of 10 BPM D. Fetal heart rate of 120 BPM

3. Diaphoresis is normal during the postpartum period.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

B. Control over one's response to stress is possible. Options B: When learning to manage stress, clients find it helpful to believe that they have the ability to control their response to it. It is impossible to avoid stress, which is a normal life experience. Options A: Stress can be positive and growth-enhancing as well as harmful. Options C: The belief that one has some control is the significant factor in minimizing stress response. Options D: Significant others are a good source of support, but coping with the utmost self-dedication is the most helpful.

During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events? A. Avoidance of stress is an important goal for living. B. Control over one's response to stress is possible. C. Most people have no control over their level of stress. D. Significant others are important to provide care and concern.

: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the ENDOTHELIAL CELLS in mom's body, which injures organs.

Fill-in-the-blank: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the _________________ in mom's body, which injures organs.* A. spiral arteries B. epithelial cells C. endothelial cells D. juxtaglomerular cells

3. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis to birth the baby.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is −2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

4. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

20 mL of blood

The doctor writes the following order for a 31-week-gravid client with symptomatic placenta previa: Weigh all vaginal pads and estimate blood loss. The nurse weighs one of the client's saturated pads at 24 grams and a dry pad at 4 grams. How many milliliters (mL) of blood can the nurse estimate the client has bled? Calculate to the nearest whole number. __________ mL.

a Late decelerations or a decrease or absence of variability indicates fetal distress. Early decelerations indicate possible compression of the​ baby's head, which can also occur if the baby is in breech position. Early​ decelerations, not late​ decelerations, often happen during the later stages of labor

The labor and delivery nurse is monitoring a client who is in labor. The client is at 37 weeks of gestation and has been induced due to signs of worsening preeclampsia. Upon the most recent​ assessment, the nurse notes late decelerations on the fetal monitoring. Which does the presence of these late decelerations likely indicate for this​ client? A. Fetal distress B. The baby possibly being in breech position C. The​ baby's head being compressed D. A normal response during later stages of labor

3. This response is correct. The involution is normal and the lochia is rubra.

The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

C. Clear, almost colorless, and containing little white specks. By 36 weeks gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.

The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: A. Clear and dark amber in color B. Milky, greenish yellow, containing shreds of mucus C. Clear, almost colorless, and containing little white specks D. Cloudy, greenish-yellow, and containing little white specks

1. The nurse would expect the client to complain of severe back pain.

The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time? 1. Complaints of severe back pain. 2. Rapid descent and effacement. 3. Irregular and hypotonic contractions. 4. Rectal pressure with bloody show.

2. Prolactin will elevate sharply in the client's bloodstream.

The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

B. This option is false. It should say: The transition phase is the SHORTEST (not longest) phase of stage 1 and contractions are very intense and long in duration.

What statement is FALSE about the transition phase of stage 1?* A. The mother may experience intense pain, irritation, nausea, and deep concentration. B. The transition phase is the longest phase of stage 1 and contractions are very intense and long in duration. C. The cervix will dilate from 8 to 10 cm. D. The transition phase ends and progresses to stage 2 of labor when the cervix has dilated to 10 cm.

B. Pudendal nerve block B, pudendal nerve block is a pharmacologic measure used to relieve pain during labor and birth.

Which of the following is not a nonpharmacologic measure? A. Breathing techniques B. Pudendal nerve block C. Focusing and imagery D. Relaxation

1. The tracing is showing a normal fetal heart tracing. No intervention is needed.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical.

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

C. The involuntary muscles do not usually have pain upon contraction. Involuntary muscles such as the heart and stomach do not suffer pain during contraction of the muscles.

Why are uterine contractions considered as unique to the human body? A. They progress as time stretches by. B. They cannot be relieved by any intervention. C. The involuntary muscles do not usually have pain upon contraction. D. The tissues surrounding the area are compressed with contractions.

D. Bulging perineum and rectum with an increase in bloody show (and presenting of the baby's head or other parts) are signs that the birth of the baby imminent.

Your laboring patient has transitioned to stage 2 of labor. What changes in the perineum indicate the birth of the baby is imminent?* A. Increase in meconium-stained fluid and retracting perineum B. Retracting perineum and anus with an increase of bloody show C. Rapid and intense contractions D. Bulging perineum and rectum with an increase in bloody show

4. A fetus in a scapular presentation is in a horizontal lie.

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

3. The most common difference between placenta previa and placenta abruption is the absence or presence of abdominal pain.

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time.

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min × 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

2. Late decelerations are indicative of uteroplacental insufficiency and indicate fetal distress. It is inappropriate to administer a central nervous system (CNS) depressant to the mother at this time.

A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1. Contraction pattern is every 3 min × 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.

C. Seizures do not occur. For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Option A: Ankle clonus indicated hyperreflexia and may precede the onset of eclampsia. Option B: Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Option D: Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A. Ankle clonus in noted B. The blood pressure decreases C. Seizures do not occur D. Scotomas are present

4. A history of scoliosis surgery is a contraindication for epidural anesthesia.

An anesthesiologist informs the nurse that a woman scheduled for cesarean section will have the procedure under general anesthesia with postoperative patient-controlled analgesia rather than under continuous epidural infusion. Which of the following would warrant this decision? 1. The woman has a history of drug addiction. 2. The woman is allergic to morphine sulfate. 3. The woman is a thirteen-year-old adolescent. 4. The woman has had surgery for scoliosis.

C. To the beginning of the next contraction. This is the way to determine the frequency of the contractions

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: A. Until the time it is completely over B. To the end of a second contraction C. To the beginning of the next contraction D. Until the time that the uterus becomes very firm

2 and 4 are correct. 2. Obese clients are at high risk for gestational diabetes. 4. Obese clients are at high risk for preeclampsia.

An obese gravid woman is being seen in the prenatal clinic. The nurse will monitor this client carefully throughout her pregnancy because she is high risk for which of the following complications of pregnancy? Select all that apply. 1. Placenta previa. 2. Gestational diabetes. 3. Abruptio placentae. 4. Preeclampsia. 5. Chromosomal defects.

D. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.

At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: A. Discontinue the catheter, if the reading is not above 80% B. Discontinue the catheter, if the reading does not go below 30% C. Advance the catheter until the reading is above 90% and continue monitoring D. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

D.

Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are released into mom's circulation, leading to clot formation and then clotting factor depletion.* A. Placenta previa, fibrinogen B. Placenta previa, platelets C. Abruptio placentae, fibrinogen D. Abruptio placentae, thromboplastin

b Renal damage or failure can occur in clients with preeclampsia. The specific gravity of the urine should be monitored. Laboratory findings of specific gravity over 1.040 correlate with oliguria and​ proteinuria, both of which are associated with renal damage. A urine specific gravity of 1.050 is not a normal finding​ (normal range 1.005 to​ 1.030). A specific gravity of 1.050 does not indicate glycosuria or a urinary tract infection.

During assessment of the hospitalized client who is​ preeclamptic, the nurse notes a urine specific gravity of 1.050 after the most recent voiding. The nurse should monitor for which​ condition? A. None—this is a normal finding B. Oliguria and proteinuria C. Glycosuria D. Urinary tract infection

C. Signs that the placenta is about to be delivered: Umbilical cord starts to lengthen, Trickling/gush of blood, and uterus changes from an oval shape to globular.

During stage 3 of labor, you note a gush of blood and that the uterus changes shape from an oval shape to globular shape. This indicates?* A. Postpartum hemorrhage B. Imminent delivery of the baby C. Signs of placental separation D. Answers B and C

3. A fourth-degree laceration extends through the rectal sphincter.

During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? 1. Into the musculature of the buttock. 2. Through the urinary meatus. 3. Through the rectal sphincter. 4. Into the head of the clitoris.

B. Uterine tetany. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.

During the period of induction of labor, a client should be observed carefully for signs of: A. Severe pain B. Uterine tetany C. Hypoglycemia D. Umbilical cord prolapse

A. Fetal body part that enters the maternal pelvis first. Presentation is the fetal body part that enters the pelvis first; it's classified by the presenting part; the three main presentations are cephalic/occipital, breech, and shoulder. Option B: The relationship of the presenting fetal part to the maternal pelvis refers to fetal position. Option C: The relationship of the long axis to the fetus to the long axis of the mother refers to fetal lie; the three possible lies are longitudinal, transverse, and oblique.

Fetal presentation refers to which of the following descriptions? A. Fetal body part that enters the maternal pelvis first B. Relationship of the presenting part to the maternal pelvis C. Relationship of the long axis of the fetus to the long axis of the mother D. A classification according to the fetal part

A. The umbilical artery in fetal circulation carries DEOXYGENATED, while the umbilical vein carries OXYGENATED.

Fill in the blank: In fetal circulation the umbilical artery carries _____________, while the umbilical vein carries ________________.* A. deoxygenated blood, oxygenated blood. B. deoxygenated/oxygenated blood, oxygen blood. C. oxygenated blood, deoxygenated blood.

D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby B. Recognize this as a behavior of the taking-hold stage C. Record the behavior as ineffective maternal-newborn attachment D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

C: 4-7 cm

In stage 1 of labor, during the active phase, the cervix dilates?* A. 1-3 cm B. 7-10 cm C. 4-7 cm D. 8-10 cm

C. Passageway, contractions, placental position and function, psychological response. The five essential factors (5 P's) are passenger (fetus), passageway (pelvis), powers (contractions), placental position and function, and psyche (psychological response of the mother).

Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors? A. Contractions, passageway, placental position and function, pattern of care B. Contractions, maternal response, placental position, psychological response C. Passageway, contractions, placental position, and function, psychological response D. Passageway, placental position and function, paternal response, psychological response

B. At 1 week to 1 year of age, peaking at 2 to 4 months. Options B: SIDS can occur anytime between 1 week and 1 year of age. Options A, C, D: The incidence peaks at 2 to 4 months of age.

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely? A. At 1 to 2 years of age. B. At 1 week to 1 year of age, peaking at 2 to 4 months. C. At 6 months to 1 year of age, peaking at 10 months. D. At 6 to 8 weeks of age.

1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines.

On examination, it is noted that a full-term primipara in active labor is right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

A. Blowing. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.

The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: A. Blowing B. Slow chest C. Shallow D. Accelerated-decelerated

A. Having the children choose or make a gift to give to the new baby upon its arrival home. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

Parents can facilitate the adjustment of their other children to a new baby by: A. Having the children choose or make a gift to give to the new baby upon its arrival home B. Emphasizing activities that keep the new baby and other children together C. Having the mother carry the new baby into the home so she can show the other children the new baby D. Reducing stress on other the by limiting their involvement in the care of the new baby

3. +3 reflexes are defined as slightly brisker than normal or slightly hyperreflexic.

The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? 1. +1. 2. +2. 3. +3. 4. +4.

A and D. Risk factors for developing placenta previa include: Maternal age >35 years old, multiples (twins etc.), already had a baby, drug use: cocaine or smoking, surgery to the uterus that will leave scarring: fibroid removal, c-section etc.

Select all the patients below who are at risk for developing placenta previa:* A. A 37 year old woman who is pregnant with her 7th child. B. A 28 year old pregnant female with chronic hypertension. C. A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen. D. A 20 year old pregnant female who is a cocaine user.

A, D, and E. These are all sign and symptoms of placenta previa. The other options are associated abruptio placentae.

Select all the signs and symptoms associated with placenta previa:* A. Painless bright red bleeding B. Concealed bleeding C. Hard, tender uterus D. Normal fetal heart rate E. Abnormal fetal position F. Rigid abdomen

D: Latent (early labor), Active, Transition

Stage 1 of labor includes which phases in the correct order?* A. Transition, Latent, Active B. Active, Latent, Transition C. Active, Transition, Latent D. Latent, Active, Transition

A

Sudden infant death syndrome​ (SIDS) is called a syndrome because it does not identify any disease as a cause of death. Which factors can lead to the sudden death of an​ infant? A. Abnormality to autonomic​ responses, stressors, and critical developmental period of 1 to 6 months of life B. Abnormality of vital​ signs, vulnerability to​ stimulus, and developmental age of 1 year old C. Abnormality to milk​ intake, vulnerability to​ stimulus, and developmental age after the age of 1 D. Abnormality of vital​ signs, vulnerability to​ stimulus, and critical developmental period of 10 to 12 months of life

3. Open glottal pushing is used during stage 2 of labor.

The childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

b, d, e Some predisposing risk factors for preeclampsia are maternal age of 40 years or​ older, obesity, medical history of chronic hypertension or kidney​ disease, previous​ preeclampsia/eclampsia, presence of​ multiples, and being of African descent.

The prenatal nurse is reviewing the histories of several clients recently confirmed as pregnant. Which client should the nurse identify as having a high risk for​ preeclampsia? (Select all that​ apply.) A. Hispanic decent B. Twin pregnancy C. Maternal age of 32 D. History of kidney disease E. Body mass index 30.1

4. Massaging of the perineum with mineral oil does help to reduce perineal tearing.

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil.

2. Clients should be advised to change their pads at each voiding.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

FALSE. Stage 2 begins with the full dilation of the cervix (10 cm) and ends with the full delivery of the baby.

True or False: Stage 2 of labor begins with the delivery of the baby and ends with the delivery of the placenta.* True False

A. The stretching of the perineal tissue. A, because the perineal tissue is stretched widely during birth which gives great pain to the woman.

What contributes mostly to the pain during birth? A. The stretching of the perineal tissue. B. The constriction of the blood vessels. C. The anoxia to the cells. D. The pressure of the fetal presenting part against the tissues.

A. Respiratory depression A, meperidine can cross the placenta and can cause respiratory depression to the fetus.

What is the effect of Meperidine (demerol) to the fetus? A. Respiratory depression B. CNS depression C. The fetus becomes small for its gestational age. D. Fetal hypotension

1. Fundal heights increase during pregnancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

2. These are characteristic actions of laboring women who are in transition.

Without doing a vaginal examination, a nurse concludes that a primigravida, who has received no medications during her labor, is in transition. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman fell asleep during a contraction. 2. The woman yelled at her partner and vomited. 3. The woman laughed at something on the television. 4. The woman began pushing with each contraction.

2. This is appropriate. The side rails and the headboard should be padded.

A client is being admitted to the labor suite with a diagnosis of eclampsia. The fetal heart rate tracing shows moderate variability with early decelerations. Which of the following actions by the nurse is appropriate at this time? 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails and head of the bed. 3. Provide the client with needed stimulation. 4. Provide the client with grief counseling.

C. All the other options are CORRECT. Option C is FALSE. This is a type of placenta previa called marginal (or low-lying). There is a chance the woman can delivery vaginally, but if the placenta was completely over the cervix or partially covering it a c-section would be required. At the 20 week ultrasound the location of the placenta is detected. The location will be re-evaluated at about 32 weeks. If a placenta is found to be low lying there is a chance the placenta will move upward (away from the cervix) as the uterus grows to accommodate the baby.

A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the placenta is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE about this finding:* A. This is known as marginal placenta previa. B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated with another ultrasound at about 32 weeks gestation. C. The patient will need to have a c-section and cannot deliver vaginally. D. The woman should report any bleeding immediately to the doctor.

2. A frequency pattern of every 3 minutes is ideal.

The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 130 seconds. 4. Attitude flexed.

1, 3, 4, and 5 are correct. 1. The client should be assessed for tachycardia, which could indicate that the client is bleeding internally. 3. This client's signs and symptoms are consistent with both spontaneous abortion and hydatidiform mole. Although this client is only at 12 weeks' gestation, if she has a hydatidiform mole, she may be exhibiting signs of preeclampia, including headache and hypertension. 4. This client's signs and symptoms are consistent with both spontaneous abortion and hydatidiform mole. To determine whether or not the patient is carrying a viable fetus, the nurse should check the fetal heart rate. 5. This client's signs and symptoms are consistent with both spontaneous abortion and hydatidiform mole. Although this client is only 12 weeks' gestation, if she has a hydatidiform mole, she may be exhibiting signs of preeclampia, including headache and hypertension.

A 12-week-gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. Which of the following signs/symptoms should the nurse assess this client for? Select all that apply. 1. Tachycardia. 2. Referred shoulder pain. 3. Headache. 4. Fetal heart dysrhythmias. 5. Hypertension.

2. The nurse should assess the client's blood pressure.

A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

4. Epigastric pain is associated with the liver involvement of HELLP syndrome.

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

B. Preeclampisa is a risk factor for experiencing abruptio placentae. The patient is at risk for developing this condition again since she is currently experiencing uncontrolled hypertension with this pregnancy.

A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What risk factor below found in the patient's health history places her at risk for abruptio placentae?* A. childhood polio B. preeclampisa C. c-section D. her age

2. The nurse would expect to see papilledema.

A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus.

B, C, and E. Option A is wrong because there may be an INCREASE in fundal height (not decrease) due to concealed bleeding. Option D is wrong because this tends to occur in placenta previa because the placenta attaches too low in the uterus at the cervical opening.

A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can present with abruptio placentae? Select all that apply:* A. Decrease in fundal height B. Hard abdomen C. Fetal distress D. Abnormal fetal position E. Tender uterus

2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate.

B, E, F, and G. These options are topics the nurse wants to include in the patient's teaching with preeclampsia. Option A is wrong because the patient should report a weight gain of >2 lbs (NOT 4 lbs) in one week. Option C is wrong become it is no longer recommended the patient restrict salt in diet but limit it. Option D is wrong because a headache and vision changes are serious complications that may indicate the development of eclampsia, and the patient should report it immediately.

A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The nurse will include what information in the patient's education? Select all that apply:* A. Report weight gain of >4 lbs in one week to physician B. Incorporate foods like eggs, nuts, fish, meat in your diet C. Follow a no salt diet D. Headache and vision changes are expected side effects of this condition and cause no reason for concern. E. Importance of monitoring urine protein at home F. Lying on left-side is recommended along with rest G. Report a decrease in fetal activity immediately

E. The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: EARLY: flushing or feeling hot/warm, later on: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.

A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician?* A. Deep tendon reflex 4+ B. Respiratory rate of 13 breaths per minute C. Urinary output of 600 mL over 12 hours D. Clonus presenting in the lower extremities E. Patient reports flushing or feeling hot

B. Abruptio placentae The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae.

A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? A. Placenta previa B. Abruptio placentae C. Ectopic pregnancy D. Spontaneous abortion

4. Because of the heavy lochia, the nurse should notify the woman's health care provider.

A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

1. LMA position is consistent with that information.

A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. RScT (right scapular transverse). 4. ROP (right occiput posterior).

d Theory suggests that increased estrogen levels allow the myometrium to become more sensitive to oxytocin. This sensitivity allows for the initiation of uterine contractions. In​ labor, progesterone levels​ decrease, not increase. Theory suggests that decreased progesterone levels increase myometrial contractility. Research shows an association between​ prostaglandin-producing agents stored in the fetal membranes and the onset of labor. Corticosteroids are increased during pregnancy and labor.

A client at 39 weeks of gestation is demonstrating signs of labor. Which hormonal action is responsible for the onset of​ labor? A. Decrease in corticosteroids B. Increase in progesterone C. Decrease in prostaglandins D. Increase in estrogen

2. This client is very anxious.

A client being seen in the ED has an admitting medical diagnosis of: third-trimester bleeding: rule out placenta previa. Each time a nurse passes by the client's room, the woman asks, "Please tell me, do you think the baby will be all right?" Which of the following is an appropriate nursing diagnosis for this client? 1. Hopelessness related to possible fetal loss. 2. Anxiety related to inconclusive diagnosis. 3. Situational low self-esteem related to blood loss. 4. Potential for altered parenting related to inexperience.

1, 2, 3, and 5 are correct. 1. Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. 2. The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. 3. The client's age should also be noted before the physical assessment is begun. 5 The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth— should also be noted before a physical assessment is begun.

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

3. The client's bladder should be palpated.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.

1. These are the classic signs of water intoxication

A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.

2. The urinary output is the likely cause of the client's changes.

A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104 bpm. 2. Urinary output 240 mL/12 hr. 3. Blood pressure 160/120. 4. Temperature 100ÅãF.

1. Because the client will have a cesarean section with anesthesia, the woman should be taught coughing and deepbreathing exercises for the postoperative period.

A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.

2. The woman is showing expected signs of the active phase of labor.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

C. Uterine rupture. Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. With placental abruption, the client typically complains of vaginal bleeding and constant abdominal pain.

A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms? A. Hysteria compounded by the flu B. Placental abruption C. Uterine rupture D. Dysfunctional labor

A. Auscultating the fetal heart. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on the admission of this client would be: A. Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she last ate D. Ascertaining whether the membranes were ruptured

3. To assess clonus, the nurse should dorsiflex the woman's foot.

A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? 1. Strike the woman's patellar tendon. 2. Palpate the woman's ankle. 3. Dorsiflex the woman's foot. 4. Position the woman's feet flat on the floor.

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

2. The woman's privacy should be maintained while she is resting.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

1 and 3 are correct. 1. This is a sign of placental separation. 3. This is a sign of placental separation.

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

4. A serum magnesium level of 9 g/dL is dangerously high. The health care practitioner should be notified.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.

4. Terbutaline (Brethine) is a smooth, muscle-relaxing agent. It would be administered prior to an external version.

A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).

1, 2, 3, and 5 are correct. 1. The nurse must check the client's blood type. 2. The nurse must check the client's name by checking the bracelet and asking the client her name. 3. The nurse must compare the client's blood type with the blood type on the infusion bag. 5. The time the infusion begins and ends must be documented.

A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1, 2, and 5 are correct. 1. When a baby is in the breech presentation, there is increased risk of prolapsed cord. 2. The presenting part is floating, which increases the risk of prolapsed cord. 5. When a baby is in the transverse lie, there is increased risk for prolapsed cord.

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.

2. This is the best response. A right mediolateral episiotomy is angled away from the perineum and rectum.

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

b Even though the immediate crisis is​ resolved, the client may continue to have effects from​ DIC, such as impaired tissue integrity. Subcutaneous injections of heparin or a portable infusion pump may be required. The healthcare provider should be called for excessive bleeding or recurrent clotting. A referral should be made to home healthcare for IV maintenance assistanc

A client with a diagnosis of chronic disseminated intravascular coagulation​ (DIC) is being discharged home. Which statement by the client requires the nurse to follow​ up? A. ​"I will need to be on a portable infusion pump of​ heparin." B. ​"The effects of the disorder will resolve​ completely." C. ​"I should call my healthcare provider if I have excessive​ bleeding." D. ​"I understand home healthcare will visit me to monitor the​ infusion."

3. Bed rest, especially side-lying, helps to improve perfusion to the placenta.

A client with mild preeclampsia who has been advised to be on bed rest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bed rest will help you to conserve energy for your labor." 2. "Bed rest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."

a, b, d, e The nurse can and should offer support and practical help to the client and her family during this difficult time. When the client knows how to monitor her own symptoms to be able to report worsening conditions that will affect her​ baby, it can ease her mind. Some of her fears of the unknown can be allayed when she and her family are kept informed of any tests that are being performed and how the baby is doing. Talking about her concerns lets the nurse know how to best help her. Emphasizing the possibility of a preterm delivery will not contribute to a calm environment for the client.

A client with preeclampsia at 32 weeks of gestation has been admitted to the hospital with signs of a worsening condition. She tells the nurse that she is worried about injury to her baby. Which action should the nurse take to help the client remain calm about her own and her​ baby's condition?​ (Select all that​ apply.) A. Keeping the client and her family informed about fetal status B. Informing the client that a nurse will be with her to offer support during the administration of any tests for fetal​ well-being C. Informing the client that a preterm delivery may be unavoidable if she does not remain calm and her blood pressure continues to rise D. Inviting the client to identify and discuss any concerns she has about her​ baby's well-being E. Educating the client on how to monitor and record fetal movement throughout the day

c Clients with preeclampsia should lie on their left side when resting to maximize uterine and renal perfusion. Clients with preeclampsia should not lie supine. Elevating the head of bed while on the right side will not maximize blood​ flow, so this is not an accurate statement.

A client with preeclampsia who is at 36 weeks of gestation is being managed at home. During the routine prenatal​ visit, in response to the​ nurse's question concerning sleep and​ rest, the client indicates that she can rest pretty well on her right side with a pillow under her abdomen. How should the nurse respond to this​ information? A. ​"When you are resting on your right​ side, make sure to also elevate your head above the level of your​ abdomen, which greatly maximizes blood flow to your​ uterus." B. ​"It is fine to lie on your right​ side, but make sure to frequently switch to a supine position to help increase blood​ flow." C. ​"It would be best for you to lie on your left side when resting to help the blood flow to your uterus and​ kidneys." D. ​"Rather than sleep on your right​ side, you should sleep on your back with your upper body and head elevated at least 30 to 45​ degrees."

2. The nurse's goal at this point must be the delivery of a healthy baby.

A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.

1, 3, 4, and 5 are correct. 1. Passive range-of-motion will help to decrease the potential for muscle atrophy and thrombus formation. 3. This client is separated from family. The separation can lead to depression. Decorating the room and enabling family to visit freely is very important. 4. A high-fiber diet will help to maintain normal bowel function. 5. Deep breathing exercises are important to maintain the client's respiratory function.

A client, 32 weeks' gestation with placenta previa, is on total bed rest. The physician expects her to be hospitalized on bed rest until her cesarean section, which is scheduled for 38 weeks' gestation. To prevent complications while in the hospital, the nurse should do which of the following? Select all that apply. 1. Perform passive range-of-motion exercises. 2. Restrict the fluid intake of the client. 3. Decorate the room with pictures of family. 4. Encourage the client to eat a high-fiber diet. 5. Teach the client deep-breathing exercises.

4. This response shows that the nurse has an understanding of the client's feelings.

A client, G1 P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

2. The pulse is the highest priority in this situation.

A gravid client is admitted with a diagnosis of third-trimester bleeding. It is priority for the nurse to assess for a change in which of the following vital signs? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood pressure.

D. Occiput posterior. A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: A. Breech B. Transverse C. Occiput anterior D. Occiput posterior

D. Oxygenation. Oxygenation of the fetus may be indirectly assessed through fetal monitoring by closely examining the fetal heart rate strip. Accelerations in the fetal heart rate strip indicate good oxygenation, while decelerations in the fetal heart rate sometimes indicate poor fetal oxygenation.

A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? A. Gender of the fetus B. Fetal position C. Labor progress D. Oxygenation

C. Active phase. Cervical dilation occurs more rapidly during the active phase than any of the previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7 cm. Options A and B: The preparatory, or latent, phase begins with the onset of regular uterine contractions and ends when rapid cervical dilation begins. Option D: Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.

A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly? A. Preparatory phase B. Latent phase C. Active phase D. Transition phase

1. This action is appropriate. It is very likely that this client is fully dilated because she is complaining of the urge to push.

A laboring woman, G4 P3003, who was 6 cm dilated 1 hour ago cries, "Hurry. I have to go to the bathroom to have a bowel movement." The nurse notes that there is an increase in bloody show. Which of the following actions by the nurse is appropriate? 1. Assess cervical dilation. 2. Help the woman to the bathroom. 3. Ask the woman if she needs pain medicine. 4. Check the fetal heart rate.

2. The nurse is using reflection to acknowledge the client's concerns.

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

A. Swelling of the calf in one leg. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis. Options B, C, and D: Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolong); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC.

A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria

C. Obtain equipment for a manual pelvic examination. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and Placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. Option A: A diagnosis of placenta previa is made by ultrasound. Option B: External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia. Option D: The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A. Prepare the client for an ultrasound B. Obtain equipment for external electronic fetal heart monitoring C. Obtain equipment for a manual pelvic examination D. Prepare to draw a Hgb and Hct blood sample

C. Obtain equipment for a manual pelvic examination. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A. Prepare the client for an ultrasound B. Obtain equipment for external electronic fetal heart monitoring C. Obtain equipment for a manual pelvic examination D. Prepare to draw a Hgb and Hct blood sample

C. So that each fetal heart rate is monitored separately. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.

A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: A. Over the fetus that is most anterior to the mother's abdomen B. Over the fetus that is most posterior to the mother's abdomen C. So that each fetal heart rate is monitored separately D. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

3. The blood pressure should be assessed before administering Methergine.

A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h °ø 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

1. The obstetric conjugate is the shortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions.

D The nurse needs to ask investigative and​ open-ended questions to determine the cause and manner of the​ infant's death. Personal questions and insurance coverage questions are not the priority. Health history questions are asked about the infant and the pregnancy history of the mother but not about the father.

A mother called 911 after finding her​ 2-month-old son unresponsive. The infant was brought to the emergency department and pronounced dead with the preliminary findings of sudden infant death syndrome​ (SIDS). Which type of questions should the nurse ask the​ parents? A. Insurance coverage questions B. Health history questions about the father C. Personal questions D. Investigative questions

3. A large empty drawer has a firm bottom so that the baby is unlikely to rebreathe his or her own carbon dioxide and the sides of the drawer will prevent the baby from falling out of "bed."

A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

C. Perform a pelvic examination. A complaint of rectal pressure usually indicates a low presenting fetal part, signaling imminent delivery. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part.

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond? A. Let the client get up to use the potty B. Allow the client to use a bedpan C. Perform a pelvic examination D. Check the fetal heart rate

4. The absence of seizures is an expected outcome related to magnesium sulfate administration.

A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output is 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.

D. Placental separation. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: A. Hematoma B. Placenta previa C. Uterine atony D. Placental separation

1. Talking and laughing are characteristic behaviors of the latent phase.

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

4. The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds.

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

B. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before a transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.

A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A. A form of biofeedback to enhance bearing down efforts during delivery B. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus C. The application of pressure to the sacrum to relieve a backache D. Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

3. Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

B. Forceps delivery. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.

A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? A. Hypotonic contractions B. Forceps delivery C. Schultz delivery D. Weak bearing down efforts

D. Changes in the shape of the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vaginal), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping.

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? A. The umbilical cord shortens in length and changes in color B. A soft and boggy uterus C. Maternal complaints of severe uterine cramping D. Changes in the shape of the uterus

C. Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. Option A: The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. Option D: An intravenous Pitocin infusion is discontinued when a late deceleration is noted.

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of Pitocin IV infusion

A. Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation. Options B and D: The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. Option C: No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord.

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A. Place the client in Trendelenburg's position B. Call the delivery room to notify the staff that the client will be transported immediately C. Gently push the cord into the vagina D. Find the closest telephone and stat page the physician

D. Hemorrhage. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? A. Disseminated intravascular coagulation B. Chronic hypertension C. Infection D. Hemorrhage

B. Assessing the baseline fetal heart rate. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority.

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? A. Identifying the types of accelerations B. Assessing the baseline fetal heart rate C. Determining the frequency of the contractions D. Determining the intensity of the contractions

C. Uterine tenderness/pain. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. Absence of abdominal pain B. A soft abdomen C. Uterine tenderness/pain D. Painless, bright red vaginal bleeding

C. Uterine tenderness/pain. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by the failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. Absence of abdominal pain B. A soft abdomen C. Uterine tenderness/pain D. Painless, bright red vaginal bleeding

2. The blood pressure rises dramatically.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

C. Oxytocin (Pitocin) infusion. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? A. Medication that will provide sedation B. Increased hydration C. Oxytocin (Pitocin) infusion D. Administration of a tocolytic medication

1. The woman should be helped into the fetal position.

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

A. Document the findings and tell the mother that the monitor indicates fetal well-being. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. C. Notify the physician or nurse-midwife of the findings. D. Reposition the mother and check the monitor for changes in the fetal tracing

B. A fetal heart rate of 90 beats per minute. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to Pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. A fetal heart rate of 90 beats per minute C. Adequate resting tone of the uterus palpated between contractions D. Increased urinary output

D. The cervix is dilated completely. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted? A. The client begins to expel clear vaginal fluid B. The contractions are regular C. The membranes have ruptured D. The cervix is dilated completely

B. Fear of losing control. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor.

A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: A. Exhaustion B. Fear of losing control C. Involuntary grunting D. Valsalva's maneuver

1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates progression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

C. Clean and maintain an open airway. The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.

A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A. Administer magnesium sulfate intravenously B. Assess the blood pressure and fetal heart rate C. Clean and maintain an open airway D. Administer oxygen by face mask

C, D, E, F, and G. When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function are monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A. Monitor maternal vital signs every 2 hours B. Notify the physician if respirations are less than 18 per minute. C. Monitor renal function and cardiac function closely D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose E. Monitor deep tendon reflexes hourly F. Monitor I and O's hourly G. Notify the physician if urinary output is less than 30 ml per hour.

4. Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruptions.

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G2 P0010, 27 weeks' gestation. 2. G3 P1101, 17 years of age. 3. G4 P2101, cancer survivor. 4. G5 P1211, cocaine abuser.

2 and 3 are correct. 2. A smoker is high risk for placenta previa. 3. A woman carrying triplets is high risk for placenta previa.

A nurse is caring for four prenatal clients in the clinic. Which of the clients is high risk for placenta previa? Select all that apply. 1. Jogger with low body mass index. 2. Primigravida who smokes 1 pack of cigarettes per day. 3. Infertility client who is carrying in vitro triplets. 4. Registered professional nurse who works 12-hour shifts. 5. Police officer on foot patrol.

1. Muslim women, who are often from Arabic countries, are expected to keep their heads covered at all times.

A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization? 1. Arabic woman. 2. Chinese woman. 3. Russian woman. 4. Greek woman.

4. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction.

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

3. It is important for the client to eat a well-balanced diet.

A nurse is counseling a preeclamptic client about her diet. Which should the nurse encourage the woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars.

D. Notify the physician or nurse midwife. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse-midwife needs to be notified.

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? A. Encourage the client's coach to continue to encourage breathing exercises B. Encourage the client to continue pushing with each contraction C. Continue monitoring the fetal heart rate D. Notify the physician or nurse midwife

A, D, B, E, C. If uterine hypertonicity occurs, the nurse immediately will intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord.

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. A. Stop of Pitocin infusion B. Perform a vaginal examination C. Reposition the client D. Check the client's blood pressure and heart rate E. Administer oxygen by face mask at 8 to 10 L/min

B. Variable decelerations. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Option A: Early decelerations result from pressure on the fetal head during a contraction. Option C: Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Option D: Short-term variability refers to the beat-to-beat range in the fetal heart rate.

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A. Early decelerations B. Variable decelerations C. Late decelerations D. Short-term variability

A. Elevated blood pressure and 3 Facial edema. The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? A. Elevated blood pressure B. Negative urinary protein C. Facial edema D. Increased respirations

2. The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin be stopped.

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4°F.

A. 1 cm above the ischial spine. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: A. 1 cm above the ischial spine B. 1 fingerbreadth below the symphysis pubis C. 1 inch below the coccyx D. 1 inch below the iliac crest

4. Most women find slow chest breathing effective during the latent phase.

A nurse is teaching a class of pregnant couples the most therapeutic breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

3. Using visual aids can help to foster learning in teens as well as adults.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal exams and blood tests. 2. Focusing the discussion on baby care rather than on labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

d The​ nurse's initial action is to apply pressure on the presenting part to avoid fetal cord compression. An amnioinfusion will not resolve the issue of a prolapsed cord. Discontinuing the oxytocin administration is​ appropriate, but it is not the​ nurse's initial action. Providing oxygen to the mother may help fetal oxygenation​ status; however, it is not the initial nursing intervention.

A nurse performs a cervical exam on a client with ruptured membranes and palpates a loop of umbilical cord. Which should be the​ nurse's initial​ action? A. Preparing for an amnioinfusion B. Stopping oxytocin administration immediately C. Administering oxygen via face rebreather at 15​ L/min D. Pushing the presenting part away to avoid cord compression

3. The client should call her primary caregiver to report swollen hands and face.

A patient is placed on bed rest at home for mild preeclampsia at 38 weeks' gestation. Which of the following must the nurse teach the patient regarding her condition? 1. Eat a sodium-restricted diet. 2. Check her temperature 4 times daily. 3. Report swollen hands and face. 4. Limit fluids to 1 liter per day.

B. All the other options are CORRECT about partial placenta previa. Option B is WRONG because this condition will present with PAINLESS, bright red bleeding NOT with pain and dark red bleeding, which happens in abruptio placentae.

A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you're educating the patient about the condition and self-care. Which statement by the patient requires you to re-educate the patient?* A. "I will avoid sexual intercourse and douching throughout the rest of the pregnancy." B. "I may start to experience dark red bleeding with pain." C. "I will have another ultrasound at 32 weeks to re-assess the placenta's location." D. "My uterus should be soft and non-tender."

1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

0.6 mL.

A postoperative cesarean section woman is to receive morphine 4 mg q 3-4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth. ___________ mL

d Prior to 34​ weeks, corticosteroids may be administered to the mother to accelerate fetal lung development and reduce preterm infant morbidity. Diuretics and antibiotics are sometimes used with the premature infant but are not indicated for administration to the mother. Unless maternal blood pressure is in the severe​ range, there is no evidence in favor of the use of antihypertensive medication.

A pregnant client at 31 weeks of gestation has been hospitalized due to worsening symptoms of preeclampsia. Which medication should the nurse anticipate administering to the client to reduce morbidity for the potentially preterm​ infant? A. Diuretic B. Antihypertensive C. Antibiotic D. Corticosteroid

b Jaundice and hyperbilirubinemia are symptoms of​ HELLP, which can occur in the postpartum​ period, usually within the first 48 hours. HELLP syndrome refers to h​emolysis, elevated liver ​enzymes, and low platelet count. The jaundice is a result of hemolysis. Jaundice is not characteristic of a​ stroke, eclampsia, or pulmonary edema.

A pregnant client diagnosed with preeclampsia at 30 weeks of gestation has just delivered a healthy infant after induction at 37 weeks of gestation. Approximately 2 hours​ postdelivery, the nurse notes that the client is becoming jaundiced. Which condition should the nurse suspect to be occurring in this​ client? A. Pulmonary edema B. HELLP C. Eclampsia D. Stroke

a Gestational hypertension occurs in the second half of pregnancy in a previously normotensive mother. Diagnosis is made after obtaining a BP greater than or equal to​ 140/90 mmHg on at least two occasions​ (at least 6 hours​ apart, after 20 weeks of​ gestation). Eclampsia is preeclampsia with the presence of seizures. Preeclampsia is defined according to the same criteria as gestational hypertension but is also accompanied by signs of end organ damage. Chronic hypertension is identified if it occurs in a pregnant client with a known history of hypertension prior to​ pregnancy, is discovered during the pregnancy prior to 20 weeks of​ gestation, or persists for more than 12 weeks postpartum.

A pregnant client has a blood pressure​ (BP) reading of​ 142/90 mmHg at the​ 32-week prenatal visit. Upon return 1 week​ later, the​ client's BP is​ 152/94 mmHg. Prior to these​ results, the client had normal BP readings. The prenatal nurse anticipates that this client will be diagnosed with which hypertensive disorder of​ pregnancy? A. Gestational hypertension B. Eclampsia C. Preeclampsia D. Chronic hypertension

A. Any bleeding, such as in the gums, petechiae, and purpura. Severe Preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: A. Any bleeding, such as in the gums, petechiae, and purpura. B. Enlargement of the breasts C. Periods of fetal movement followed by quiet periods D. Complaints of feeling hot when the room is cool

b Signs of preterm labor include cervical​ dilation, abdominal​ pain, diarrhea, lower back​ pain, pelvic​ pressure, and increased vaginal discharge.​ Headaches, elevated blood​ pressure, and decreased fetal movement are not clinical manifestations of preterm labor.

A pregnant client is admitted to the hospital in premature labor. Which assessment finding should the nurse​ anticipate? A. Decreased fetal movement B. Cervical dilation C. Headache D. Elevated blood pressure

A. Activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.

A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest B. Platelet infusion C. Immediate cesarean delivery D. Labor induction with oxytocin

D. Respirations of 10 per minute. Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden drop in the fetal heart rate and maternal heart rate and blood pressure. Option B: Therapeutic levels of magnesium are 4-7 mEq/L. Option C: Proteinuria of +3 would be noted in a client with preeclampsia.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A. Presence of deep tendon reflexes B. Serum magnesium level of 6 mEq/L C. Proteinuria of +3 D. Respirations of 10 per minute

d The magnesium sulfate infusion will be continued for 24 hours after​ delivery; due to​ this, vital signs must be taken hourly. The magnesium sulfate will not be decreased and discontinued after 4-6 ​hours, because it will need to be continued for at least 24 hours postdelivery. The client does not need to continue to lie in a left​ side-lying position after​ delivery, nor delay breastfeeding for several days. While delayed breastfeeding may occur due to the impact of the preeclampsia and administration of the magnesium​ sulfate, it does not need to be delayed for several days.

A pregnant client with a severe case of preeclampsia has just delivered a healthy preterm infant. The magnesium sulfate started prior to delivery is being continued in the postpartum period. As the postpartum nurse creates a care plan for this​ client, which intervention would she​ include? A. Reminding the client to remain in a left​ side-lying position while in bed to maximize perfusion B. Informing the client that initiation of breastfeeding will have to be delayed until the third or fourth day postpartum C. Slowly decreasing the magnesium sulfate dose to discontinue within 4-6 hours postdelivery D. Monitoring vital signs hourly for the first 24 hours

C. Disseminated intravascular coagulation (DIC). Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. Option A: Thrombocytopenia results from decreased production of platelets.Option B: ITP doesn't have a definitive cause.Option D: A patient with abruptio placentae wouldn't get heparin and, as a result, wouldn't be at risk for HATT.

A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks' gestation. She's at risk for which of the following blood dyscrasias? A. Thrombocytopenia. B. Idiopathic thrombocytopenic purpura (ITP). C. Disseminated intravascular coagulation (DIC). D. Heparin-associated thrombosis and thrombocytopenia (HATT).

2. These are signs of placental delivery.

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

3. The FH should always be assessed after each contraction during stage 2. Plus, this baby is especially at risk because the stage is prolonged and the physician is using forceps for delivery.

A woman has been in the second stage of labor for 21/2 hours. The fetal head is at +4 station and the fetal heart is showing mild late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the woman to push between contractions. 3. Assess the fetal heart rate after each contraction. 4. Advise the woman to refuse the use of forceps.

1 and 2 are correct. 1. An appropriate action by the doula is giving the woman a back massage. 2. An appropriate action by the doula is to assist the laboring woman with her breathing.

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous.

1, 2, and 4 are correct. 1. The nurse should assess the fetal heart before reporting the client's status to the health care provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 4. The nurse should assess the woman's vital signs before reporting her status.

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

3 and 5 are correct. 3. Placental abruption may develop as a result of the auto accident. 5. The woman may go into preterm labor after an auto accident.

A woman has just been admitted to the emergency department subsequent to a head-on automobile accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which of the following complications of pregnancy? Select all that apply. 1. Placenta previa. 2. Transverse fetal lie. 3. Placental abruption. 4. Severe preeclampsia. 5. Preterm labor

1. The nurse would expect to administer Narcan to the client.

A woman in active labor received Nubain (nalbuphine hydrochloride) 14 mg IV for pain relief. One half hour later her respirations are 8 rpm. The nurse reports the respiratory rate to the physician. Which of the following medications would be appropriate for the physician to order at this time? 1. Narcan (naloxone). 2. Reglan (metoclopramide). 3. Benadryl (diphenhydramine). 4. Vistaril (hydroxyzine).

3. Analgesics are central nervous system (CNS) depressants. The variability of the fetal heart rate, therefore, will be decreased.

A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

2. The woman should be encouraged to grunt during contractions.

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2. This comment is consistent with a woman in the transition phase of stage 1.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

4. Previous cesarean section is a contraindication for external version.

A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station -2. 2. 38 weeks' gestation. 3. Reactive NST. 4. Previous cesarean section.

4. When the baby's chin is on his or her chest, the baby is in the flexed attitude.

A woman who is in active labor is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

4. A vaginal examination will provide the nurse with the best information about the status of labor.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold's maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

3. The duration of the contractions is prolonged. The baby will be deprived of oxygen.

A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.

4. This client is exhibiting clear signs of true labor. Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen.

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

2. The woman is in early labor. There is no need for her to be hospitalized at this time.

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing.

42 gtt/min

After a client's placenta is birthed, the obstetrician states, "Please add 20 units of oxytocin to the intravenous and increase the drip rate to 250 mL/hr." The client has 750 mL in her IV and the IV tubing delivers fluid at the rate of 10 gtt/mL. To what drip rate should the nurse set the intravenous? ______ gtt/min

4. Moderate variability is indicative of fetal health.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

D. It should be found at or near the umbilicus. It will decrease 1 cm a day and after 10 days post-delivery it can not be palpated.

After birth, where do you expect to assess fundal height?* A. At the xiphoid process B. 5 cm below the umbilicus C. 2 cm above the pubic symphysis D. At or near the umbilicus

C. Below the umbilicus on the right side. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.

After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus at the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin

A, B, and D. The only incorrect statement is Option C. The placenta produces prostaglandins. When it is removed the production of prostaglandin production decreases, which causes the ductus arteriosus to close.

After the birth of the baby, heart circulation changes due to the closure of the shunting structures in the baby's circulatory system. Select below all the reasons for the closure of these shunting structures:* A. The pressure in the right side of the heart decreases compared to the left side. B. The resistance in the lungs decreases. C. Prostaglandin production increases. D. Oxygen levels in the baby's body increase.

2. The practitioner should increase the dosage of oxytocin at a minimum time interval of every 30 minutes.

An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.

B. Delivery of the fetus. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: A. Complete bed rest for the remainder of the pregnancy B. Delivery of the fetus C. Strict monitoring of intake and output D. The need for weekly monitoring of coagulation studies until the time of delivery

2. The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

b The American Academy of Pediatrics recommends that no soft objects be placed in the​ infant's sleep area. This includes​ pillows, soft​ toys, quilts,​ comforters, sheepskins, crib​ bumpers, or loose bedding such as blankets. A pacifier​ may, or should be offered at bedtime or​ naps, but there is no need to replace it if it falls out. An infant can be swaddled at this age. Infants should always be placed on their backs for sleeping until 1 year of age.

An unlicensed assistive personnel​ (UAP) is providing care for a​ 1-month-old infant. Which observation by the nurse of the UAP requires immediate ​follow-up? A. Offering a pacifier B. Placing a stuffed animal in the crib C. Placing the infant in supine position D. Swaddling the infant

d The priority intervention would be to provide the parents with an explanation of SIDS.​ After, the parents need time with their infant to assist with the grieving process. Calling their priest and collecting the​ infant's belongings are also important steps in the plan of care but are not the priority.

An​ 8-week-old infant who is not breathing is brought to the emergency department and pronounced dead on arrival. A preliminary finding of sudden infant death syndrome​ (SIDS) is made. Which nursing intervention with the parents should be the priority​? A. Calling their priest B. Collecting the​ infant's belongings C. Allowing them to see the infant D. Explaining SIDS

b Elevated liver enzymes and​ decreased, not​ increased, platelet count would be of the greatest concern as it may be reflective of HELLP syndrome. This syndrome is also characterized by hemolysis. A decreased creatinine or urine​ protein/creatinine ratio is not associated with the pathology of preeclampsia.

As the prenatal nurse analyzes the lab results of multiple pregnant clients seen that day for prenatal​ checks, which lab result would indicate that a client has​ preeclampsia? A. Decreased creatinine B. Elevated liver enzymes C. Increased platelet count D. Decreased urine​ protein/creatinine ratio

2. The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and buttocks at -1 station are 1 cm above the ischial spines.

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA −1 station. 2. LSP −1 station. 3. LMP +1 station. 4. LSA +1 station.

3. During extension, the baby's head is birthed.

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

The order of change during the third stage of labor is: 3, 4, 1, 2. 3. The contraction of the uterus after delivery of the baby is the first step in the third stage of labor. 4. As the uterus contracts, its surface area decreases more and more. 1. A hematoma forms behind the placenta as the placenta separates from the uterine wall after the uterus has contracted and its surface area has decreased. 2. The membranes separate from the uterine wall after the placenta separates and begins to be born.

During the third stage, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts firmly. 4. The uterine surface area dramatically decreases.

C. In the fetus before birth, the pressure in HIGHER on the right side of the heart compared to the left side. This causes the blood from the RIGHT atrium to flow into the LEFT atrium via the FORAMEN OVALE.

Fill in the blank: In the fetus' circulation before birth the pressure is ____________ on the right side of the heart compared to the left side. This causes some of the blood from the _________ atrium to flow into the __________ atrium via the ______________.* A. lower, right, left, foramen ovale B. higher, left, right, ductus arteriosus C. higher, right, left, foramen ovale D. lower, left, right, ductus venosus

B. The UMBILICAL VEIN carries oxygenated blood from the placenta to the fetus. Some of the blood flow from this structure is shunted from the LIVER to the INFERIOR VENA CAVA via the DUCTUS VENOSUS.

Fill in the blank: The ______________ carries oxygenated blood from the placenta to the fetus. Some of the blood flow from this structure is shunted from the __________ to the ___________ via the _______________.* A. umbilical artery, lungs, aorta, ductus arteriosus B. umbilical vein, liver, inferior vena cava, ductus venosus C. umbilical vein, liver, superior vena cava, ductus arteriosus D. umbilical artery, liver, inferior vena cava, ductus venosus

C: To check for clonus the nurse will have the patient dangle the leg and support the patient's lower leg. Then the nurse will quickly dorsiflex the foot. The nurse is assessing for bouncing or beating of the foot (hence the foot attempts to plantarflex). If the foot attempts to bounce or beat 3 or more times, it is positive for clonus.

How would the nurse check for clonus in a patient with preeclampsia?* A. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction. B. Assess for muscular rigidity by having the patient extend the arms and place resistance against the arms. C. Assess for beating of the foot when the foot is quickly dorsiflexed. D. Assess for dorsiflexion of the foot by quickly plantar flexing the foot.

1. The first action the nurse should take is to place the woman in the knee-chest position.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

1. The appropriate action is to provide the client with warm blankets.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in the Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

2. Hypotension is a very common side effect of regional anesthesia.

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

B. The mass palpated is the head.When the mass palpated is hard round and movable, it is the fetal head.

In Leopold's maneuver step # 3 you palpated a hard round movable mass at the supra pubic area. The correct interpretation is that the mass palpated is: A. The buttocks because the presentation is breech. B. The mass palpated is the head. C. The mass is the fetal back. D. The mass palpated is the small fetal part

D. The mass palpated is the buttocks.The palpated mass is the fetal buttocks since it is broad and soft and moves with the rest of the mass.

In Leopold's maneuver step #1, you palpated a soft, broad mass that moves with the rest of the mass. The correct interpretation of this finding is: A. The mass palpated at the fundal part is the head part. B. The presentation is breech. C. The mass palpated is the back D. The mass palpated is the buttocks.

A and B. Option A indicates positive clonus and Option B is indicative of hyperreflexia. If these findings are present it demonstrates that the central nervous system is irritated and there is a high risk of potential seizure activity. Seizure precautions should be initiated and the physician notified.

In a patient with preeclampsia, what signs and symptoms indicate that the patient has a high risk of experiencing a seizure due to central nervous system irritability? Select all that apply:* A. You note bouncing of the foot when it is quickly dorsiflexed. B. Patellar and bicep deep tendon reflexes are graded 4+. C. Platelet count 200,000 D. Patient reports a decrease in headache pain.

1. Headache and decreased output are signs of preeclampsia.

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week-gravid client to call the office if she experiences which of the following? 1. Headache and decreased output. 2. Puffy feet. 3. Hemorrhoids and vaginal discharge. 4. Backache.

4. This is the best response.

It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

B. Stop the Pitocin. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin which stimulates the uterus to contract. Option A: The woman is already in an appropriate position for uteroplacental perfusion. Option C: Elevation of her legs would be appropriate if hypotension were present. Option D: Oxygen is appropriate but not the immediate action

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: A. Change the woman's position B. Stop the Pitocin C. Elevate the woman's legs D. Administer oxygen via a tight mask at 8 to 10 liters/minute

A. Placenta previa Placenta previa with painless vaginal bleeding.

Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected? a. Placenta previa b. Abruptio placentae c. Premature labor d. Sexually transmitted disease

D. Uses the peri bottle to rinse upward into her vagina. The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum B. Washes from symphysis pubis back to episiotomy C. Changes her perineal pad every 2 - 3 hours D. Uses the peri bottle to rinse upward into her vagina

B, C, D, E, and G. Risk factors for preeclampsia include: History of preeclampsia or family history, first pregnancy (primigravida), significant health history prior to pregnancy: diabetes, lupus, high blood pressure, kidney disease, Obese: BMI >30, having more than one baby (twins, triplets etc.), age (young <18 or advanced >35).

Select all the risk factors below that increases a woman's risk for developing preeclampsia:* A. Nulligravida B. Primigravida C. BMI 34 D. Pregnant with twins E. Maternal history of preeclampsia F. Age: 25-years-old G. History of Lupus and Diabetes

B, C, and E. These structures play a role with shunting blood from the lungs and liver. The ductus venosus shunts some blood from the LIVER, and the foramen ovale and ductus arteriosus shunt blood from the LUNGS.

Select the structures in fetal circulation that play a role with shunting blood away from the lungs and liver? Select all that apply:* A. Umbilical vein B. Ductus venosus C. Foramen ovale D. Umbilical artery E. Ductus arteriosus

B. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetusCarbon monoxide is one of the substances found in cigarette smoke. This substance diminishes the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood reaching the fetus.

Smoking is contraindicated in pregnancy because A. Nicotine causes vasodilation of the mother's blood vessels B. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus C. The smoke will make the fetus, and the mother feel dizzy D. Nicotine will cause vasoconstriction of the fetal blood vessels

A. Calcium gluconate. Calcium gluconate is the antidote for magnesium toxicity. Ten ml of 10% calcium gluconate is given IV push over 3-5 minutes. Hydralazine is given for sustained elevated blood pressures in preeclamptic clients.

The antagonist for magnesium sulfate should be readily available to any client receiving IV magnesium. Which of the following drugs is the antidote for magnesium toxicity? A. Calcium gluconate B. Hydralazine (Apresoline) C. Narcan D. RhoGAM

1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconiumstained fluid. The client needs to be assessed.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

A. Upper uterine portion The embryo's normal nidation site is the upper portion of the uterus. If the implantation is in the lower segment, this is an abnormal condition called placenta previa.

The common normal site of nidation/implantation in the uterus is: A. Upper uterine portion B. Mid-uterine area C. Lower uterine segment D. Lower cervical segment

3. It is likely that the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelerations are seen on the FH monitor.

The health care practitioner performed an amniotomy 5 minutes ago on a client, G3 P1011, 40 weeks' gestation, -4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is post-term. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.

1. The nurse's findings upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior position (LOA)—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

B. Vertical positionVertical position means the fetal spine is parallel to the maternal spine thus making it easy for the fetus to go out the birth canal. Options A and C: If transverse or oblique, the fetus can't be delivered normally per vagina.

The most common normal position of the fetus in utero is: A. Transverse position B. Vertical position C. Oblique position D. None of the above

d Concerns have been raised about the association of bed​ sharing, SIDS, and infant suffocation. Lack of​ sleep, increased​ bonding, and being unable to properly breastfeed are not among the risk factors associated with SIDS while sharing a bed with an infant.

The mother of a​ 2-month-old infant breastfeeds and thinks that it is easier to have her infant sleep with her. Which factor places the infant at an increased risk for sudden infant death syndrome​ (SIDS)? A. Increased bonding B. Lack of sleep C. Improper breastfeeding D. Infant suffocation

1. This is the correct response. A fetal heart rate of 152 is normal.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

a Reposition the mother to improve uteroplacental perfusion and then implement continuous fetal monitoring to evaluate the intervention. An FHR of 90​ beats/min is abnormally low. Any abnormalities detected by intermittent auscultation require further evaluation by continuous electronic monitoring. Obtaining maternal vital signs and notifying the healthcare provider are all appropriate responses to FHR​ abnormalities, but uteroplacental perfusion is a key to providing the fetus with adequate oxygenation while implementing continuous fetal monitoring to evaluate the effectiveness of the intervention

The nurse auscultates the fetal heart rate​ (FHR) with a Doppler for a client in active​ labor, and determines that it is 90​ beats/min. Which action should the nurse identify as a priority​? A. Repositioning the mother laterally B. Calling the healthcare provider C. Applying a continuous electronic fetal monitor D. Taking the​ mother's blood pressure

c Widespread activation of either the intrinsic or the extrinsic pathways results in excess release of thrombin. Thrombin and emboli cause tissue and organ damage. Clotting factors are consumed faster than they are​ replaced, leading to excessive bleeding.

The nurse concludes that both clotting and bleeding occur during disseminated intravascular coagulation​ (DIC) due to which​ process? A. Activation of intrinsic pathways results in release of excess clotting factors. B. Only clotting occurs during​ DIC, as clotting factors are replaced and available to prevent excess bleeding. C. Excess release of thrombin uses up clotting factors quicker than they can be replaced. D. Tissue damage from bleeding uses up clotting factors quicker than they can be replaced.

4. Intermittent auscultation should be performed for 1 full minute after contractions end.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Periodically during the peak of contractions. 4. For 1 minute immediately after contractions.

3. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain.

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

b Decreasing environmental stimuli helps reduce the risk of seizures that may occur for a client with preeclampsia. Lying on the left side maximizes uterine and renal profusion. Elevating the lower extremities helps prevent edema. Decreased fetal movement is associated with fetal hypoxia.

The nurse has discussed methods to decrease the risk of seizure activity with a client diagnosed with preeclampsia. Which client statement indicates an understanding of the​ teaching? A. ​"I will keep my legs​ elevated." B. ​"I will make sure everything is​ quiet." C. ​"I will let you know if I do not feel my baby​ move." D. ​"I will not lay flat on my​ back."

2 and 4 are correct. 2. This statement is correct. The woman should wash her hands before and after performing pericare care. 4. This statement is accurate.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

A Sudden infant death syndrome​ (SIDS) is the sudden death of an apparently healthy infant that remains unexplained after other possible causes have been ruled out through​ autopsy, death scene​ investigation, and review of the medical history. Lab​ analysis, chest​ x-ray, and genetic mapping are not used to rule out the possible causes of an infant death due to SIDS.

The nurse includes information in a presentation that sudden infant death syndrome​ (SIDS) remains unexplained after other possible causes have been ruled out. The nurse understands that which procedure is used to rule out the possible causes of​ SIDS? A. Autopsy B. Genetic mapping C. Chest​ x-ray D. Lab analysis

a This client is in the latent phase of the first stage of labor. During this​ time, it is normal for cervical dilation to progress at less than 1 cm every 2 hours. A prolonged latent phase may be treated with therapeutic rest and hydration. It is not necessary to augment the​ client's labor with oxytocin or prepare for a cesarean delivery. Rupturing membranes at a​ ?2 station places the client at risk for a prolapsed cord. Next Question

The nurse is admitting a client at 39 weeks of gestation scheduled for a trial of labor after a previous cesarean birth who reports having uncomfortable contractions for a whole day and sleeplessness at night. The​ client's cervix is 3​ cm, 50%​ effaced, and the baby is at -2 station. The​ baby's heart rate is 144​ beats/min and contractions are palpable every 5-7 minutes. Which describes the​ nurse's anticipated​ action? A. Encouraging fluids by mouth B. Preparing for a possible cesarean delivery C. Initiating IV oxytocin D. Assisting with artificial rupture of membranes

d The most appropriate response to the client​ is, "Due to the risk factors a cesarean birth​ has, it is only recommended if the benefits clearly outweigh the​ risks." Cesarean births have a higher risk of​ bleeding, infection, and injury to other structures. Future pregnancy may be complicated by uterine scar separation and placenta accreta.​ Furthermore, risks to the mother increase with each consecutive surgery. The other statements provide inaccurate information to the client.

The nurse is admitting a client for an induction of labor. The client asks if it would just be easier to have a cesarean birth because she is afraid of the pain. Which response from the nurse is most​ appropriate? A. ​"That will be so much more convenient for you. Then you can schedule the delivery of your next baby by repeat​ cesarean." B. ​"You should avoid having a cesarean birth at all costs. Your body is designed to give​ birth." C. ​"The process of inducing your labor could take several days. Would you like to speak to your​ obstetrician?" D. ​"Due to the risk factors a cesarean birth​ has, it is only recommended if the benefits clearly outweigh the​ risks."

b Clients who are hospitalized with preeclampsia and are on bedrest should be assessed for uterine bleeding at each assessment. Fluid intake and possible vision changes should be assessed routinely but do not need to be assessed during each assessment. Bladder distention would not be a concern requiring assessment for the client with preeclampsia.

The nurse is assessing a client at 35 weeks of gestation. The client has been hospitalized for the past 2 weeks on bedrest due to preeclampsia. Which question should the nurse ask the client at each​ assessment? A. ​"Are you drinking enough​ water?" B. ​"Are you having any uterine​ bleeding?" C. ​"Are you having any vision​ changes?" D. ​"Do you feel that your bladder is​ distended?"

a, b, d, e Lightening occurs as the fetus descends or drops down into the maternal pelvis. Bloody show usually occurs within 48 hours of the onset of true​ labor, and is also associated with the loss of the cervical mucus plug. Braxton Hicks​ contractions, or false​ labor, occur as the body is priming itself for the impending labor and delivery. Prior to the onset of​ labor, women generally have a surge of energy.

The nurse is assessing a client at 38 weeks of gestation. Which premonitory signs may occur before the onset of​ labor? (Select all that​ apply.) A. Loss of cervical mucus plug B. Bloody show C. Fatigue D. Lightening E. Braxton Hicks contractions

a Eclampsia is preeclampsia with the presence of seizures. Seizures would indicate progression to eclampsia. Visual​ disturbances, pulmonary​ edema, and elevated liver enzymes are all clinical manifestations of​ preeclampsia, but do not indicate progression to eclampsia.

The nurse is monitoring a client who is hospitalized at 30 weeks of gestation for preeclampsia. Which manifestation should the nurse recognize as indicating progression to​ eclampsia? A. Seizures B. Visual disturbances C. Elevated liver enzymes D. Pulmonary edema

2. A baseline FH of 140 to 150 is a baseline showing moderate, or normal, variability. Decelerations that mirror contractions are defined as early decelerations. These are related to head compression and are expected during transition and second stage labor.

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, fullterm gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. 2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Baseline of 140 to 142 with no obvious decelerations or accelerations.

2. Station is assessed by palpating the ischial spines.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. The nurse would expect to see well-approximated edges.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2, 3, and 5 are correct. 2. There should be blood available in the blood bank in case the woman begins to bleed. 3. The nurse would expect to keep the woman on bed rest with bathroom privileges only. 5. The nurse would expect that weekly biophysical profiles would be done to assess fetal well-being.

The nurse is caring for a 32-week G8 P7007 with placenta previa. Which of the following interventions would the nurse expect to perform? Select all that apply. 1. Daily contraction stress tests. 2. Blood type and cross match. 3. Bed rest with passive range-of-motion exercises. 4. Daily serum electrolyte assessments. 5. Weekly biophysical profiles.

c During the fourth stage of​ labor, the​ nurse's priority is a fundal assessment. The fundus should be firm and midline about midway between the symphysis pubis and umbilicus. During the fourth stage of​ labor, nurses can expect changes in the maternal vital signs. The nurse should expect to perform assessments every 15 minutes​ × 4, then every 30 minutes​ × 2, then every hour until stable. The nurse will expect moderate vaginal drainage​ (lochia rubra). The woman may report feeling​ chilly, thirsty,​ hungry, and tired.

The nurse is caring for a client going into the fourth stage of labor. Which is a priority nursing assessment during this​ stage? A. Vaginal discharge assessment every 4 hours B. Hourly maternal vital signs C. Fundal assessment D. Oxygen saturation every 4 hours

2. This is the best response for the nurse to make. The nurse is providing the client with accurate, reassuring information without guaranteeing that there will definitely be a positive outcome.

The nurse is caring for a client in labor and delivery with the following history: G2 P1000, 39 weeks' gestation in transition phase, FH 135 with early decelerations. The client states, "I'm so scared. Please make sure the baby is OK!" Which of the following responses by the nurse is appropriate? 1. "There is absolutely nothing to worry about." 2. "The fetal heart rate is within normal limits." 3. "How did your first baby die?" 4. "Was your first baby preterm?"

A. Change the client's position. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side-lying may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression.

The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A. Change the client's position. B. Prepare for emergency cesarean section. C. Administer oxygen. D. Check for placenta previa.

d A client who has made no progress in the second stage of labor and is at​ +3 station may require an​ instrument-assisted delivery. Perineal hygiene and emotional support will not facilitate the delivery. A full bladder can impede​ delivery, but there is no indication that this is the case at this time.

The nurse is caring for a client in the second stage of labor who is at​ +3 station, but has not made further progress over the last 3 hours. The nurse notifies the healthcare provider. Which action should the nurse anticipate the healthcare provider to​ order? A. Emotional support B. Perineal hygiene C. Inserting a urinary catheter to empty the bladder D. Setting up for an​ instrument-assisted delivery

3. The woman should turn, cough, and deep breathe every 2 hours.

The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

b, c, d, e Microclots in the pulmonary vasculature can cause impaired gas exchange. Bedrest reduces oxygen demand and cardiac workload. The head of the bed is elevated to promote diaphragmatic movement and alveolar ventilation. Monitoring oxygenation saturation measures gas exchange. Controlling pain and anxiety reduces respiratory rate and improves the quality of ventilation and gas exchange. Deep breathing and effective coughing clear airways and improve alveolar ventilation and oxygenation

The nurse is caring for a client who has signs of acute disseminated intravascular coagulation. Which intervention is​ appropriate? (Select all that​ apply.) A. Encourage ambulation. B. Administer analgesics and antianxiety​ medications, as ordered. C. Continuously monitor oxygen saturation. D. Encourage deep breathing and effective coughing exercises. E. Elevate the head of the bed.

a, b, c, d Nursing assessment for health history should include family history of​ SIDS, breathing​ patterns, sleep​ patterns, and exposure to smoke. Maternal history of miscarriage is not identified as a causative factor in the development of SIDS.

The nurse is performing a health history for assessment for sudden infant death syndrome​ (SIDS). The nurse should focus on which​ area? (Select all that​ apply.) A. Breathing patterns B. Exposure to smoke C. Sleep patterns D. Family history of SIDS E. Maternal history of miscarriage

d The​ nurse's role during an amniotomy is to document the characteristics of the amniotic fluid as well as monitor the fetal heart rate​ (FHR). The characteristics of amniotic fluid that are noted include its​ color, odor, and quantity. Perineal care is important but not the most important thing to do during an amniotomy. The Bishop score is not necessary prior to an amniotomy for a client who is 4 cm dilated. If an epidural is in place prior to an​ amniotomy, decreasing the dose is not within in the scope of practice for nursing and is not necessary.

The nurse is caring for a client who is 4 cm dilated. The healthcare provider performs an amniotomy to augment the​ client's labor. Which correctly describes the​ nurse's role during an​ amniotomy? A. Providing perineal care B. Evaluating the Bishop score C. Decreasing the epidural dose D. Assessing the amniotic fluid

b The nurse will reposition the ultrasound transducer to obtain a continuous fetal heart rate tracing. A nonreassuring fetal heart rate pattern cannot be identified with an intermittent tracing. A suspected fetal arrhythmia may not be noted with an intermittent tracing. It is not necessary to reposition the mother on her left side to improve uteroplacental perfusion unless the tracing is nonreassuring.

The nurse is caring for a client who is undergoing a labor induction and reports feeling uncomfortable. The client declines​ analgesia, instead preferring to walk and change positions frequently. The nurse notes frequent gaps in the fetal heart rate tracing and sections showing wide disparities in baseline fetal heart rate. Which action should the nurse​ take? A. Notify the healthcare provider of a suspected fetal arrhythmia. B. Reposition the ultrasound transducer. C. Continue to monitor the client. D. Position the mother on her left side for maximum uteroplacental perfusion.

a, c, d, e Care of the client with DIC may include mechanical ventilation and control of organ damage from reduced tissue perfusion. Clients with DIC may develop intracranial bleeding resulting in altered levels of​ consciousness, damage to the respiratory​ center, and increased intracranial pressure. Monitoring for client allergies is an independent nursing intervention that would be implemented for all clients.

The nurse is caring for a client with disseminated intravascular coagulation​ (DIC). Which collaborative therapy should the nurse include in the​ client's care?​ (Select all that​ apply.) A. Monitoring for intracranial bleeding B. Monitoring client allergies C. Monitoring for organ damage D. Monitoring need for mechanical ventilation E. Monitoring intracranial pressure

d Fibrinogen levels may be normal or even decreased in circumstances where elevated levels are expected.​ D-dimer will be elevated in both acute and chronic DIC. Decreased platelet count and the presence of schistocytes on the CBC indicate DIC. Fibrin degradation products will be increased as a result of fibrinolysis.

The nurse is caring for a client with suspected disseminated intravascular coagulation​ (DIC). Which diagnostic test result supports the diagnosis of​ DIC? A. Decreased fibrin degradation products B. Decreased​ D-dimer C. Increased platelet count D. Normal fibrinogen levels

b, c, e Interviews of the family should focus on determining the circumstances surrounding the​ infant's death. Questions should center on the health of the​ infant, dietary​ intake, and history of congenital birth defects. The health of the parents and history of infant reflux do not help to determine the circumstances surrounding the​ infant's death, as these factors have not been linked to causing​ SIDS-related deaths.

The nurse is caring for a couple whose infant has died of suspected sudden infant death syndrome​ (SIDS). When asking the couple about the circumstances surrounding the​ infant's death, which factor should the nurse focus​ on? (Select all that​ apply.) A. Health of the parents B. Health of the infant C. ​Infant's dietary intake D. History of infant reflux E. History of the​ infant's congenital heart defects

3, 4, and 5 are correct. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

1. It is appropriate to apply an ice pack to the area.

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

3. Observant Jewish women are expected to have their elbows covered at all times. A long-sleeved gown, therefore, should be provided for them.

The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care? 1. Encourage the father to hold his partner's hand during labor. 2. Ask the woman if she would like to speak with her priest. 3. Provide the woman with a long-sleeved hospital gown. 4. Place an order for the woman's postpartum vegetarian diet.

2. The side rails of an eclamptic client's bed should be padded.

The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

a It is unnecessary to restrict intake in any way for the client that is low risk in the latent phase of labor.​ Furthermore, 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

The nurse is caring for a​ low-risk client in the latent phase of labor. The client​ states, "I am hungry and would like something light to​ eat." Which describes the​ nurse's understanding of fluid and nutritional intake during​ labor? A. Fluids and foods may be offered. B. The client can have only ice chips. C. Fluid and foods are avoided during labor. D. The client can have only fluids and ice chips.

1. The cervix is thin.

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station −2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

a, b, c, d The nurse who is supporting the​ couple's psychosocial needs and providing the couple with collaborative therapy resources will assist the family in contacting the​ family's pastor or clergy​ member, provide the family with resources on grief counselors and support​ groups, and provide empathy toward the​ infant's family. Asking the family about funeral homes is not​ supportive, and the family may not be ready to discuss this.

The nurse is caring for parents who are grieving over the death of their infant who is suspected to have died of sudden infant death syndrome​ (SIDS). Which response by the nurse is​ therapeutic? (Select all that​ apply.) A. ​"I will provide you with a list of local grief​ counselors." B. ​"I am sorry you are going through this. Would you like to talk to me about your​ child?" C. ​"Is there a pastor or clergy member you would like me to​ call?" D. ​"The infant loss support group meets every​ Tuesday." E. ​"Which funeral home would you like me to​ contact?"

b, d, e Nursing outcomes or goals for the parents of a child who has died as a result of SIDS should focus on the​ parent's psychosocial wellness and demonstration of the​ parents' effective coping. A couple who seeks clarity on the exact cause of death is not necessarily displaying effective coping or psychosocial​ wellness, because the exact cause of the​ SIDS-related death is often not discovered. Acceptable grief is a subjective​ goal, as everyone grieves differently

The nurse is caring for parents whose infant has died from sudden infant death syndrome​ (SIDS). When planning​ care, which outcome is appropriate for the nurse to​ establish? (Select all that​ apply.) A. The parents will demonstrate acceptable grief. B. The parents will demonstrate effective coping. C. The parents will seek clarity on the exact cause of death. D. The parents will acknowledge the grieving process. E. The parents will seek therapy for psychosocial wellness

a, e The nurse who is implementing appropriate nursing interventions for a grieving couple may offer to contact a grief counselor to help the parents.​ Also, the nurse may call the​ parents' church leader after a request from the parents. Calling and requesting the immediate presence of the hospital chaplain is not culturally​ sensitive, because not all grieving clients would like this. The nurse is not responsible for calling the police to begin the death investigation following an​ infant's death from SIDS. The nurse should not contact the grieving​ parents' other children to discuss the​ infant's death

The nurse is caring for parents whose infant has died from sudden infant death syndrome​ (SIDS). Which nursing intervention is appropriate for the nurse to​ implement? (Select all that​ apply.) A. Calling the​ parents' church leader after a request from the parents B. Calling the police to begin the death investigation C. Offering to contact the​ parents' other children to discuss the​ infant's death D. Calling the hospital chaplain and requesting her presence immediately E. Offering to contact a grief counselor to help the parents

3. Epidurals do not fully sedate the motor nerves of the client. Epidural clients are capable of moving their lower extremities even when fully pain free.

The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Spinal clients complain of nausea and vomiting.

3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

a, b, e Laboratory findings that support a diagnosis of DIC include the presence of​ schistocytes, a decreased platelet​ count, and an increase in fibrin degradation products or fibrin split products. The client with DIC would not have an elevated hemoglobin or shortened prothrombin time.

The nurse is evaluating the lab results for a client suspected of having disseminated intravascular coagulation​ (DIC). Which laboratory finding supports the​ diagnosis? (Select all that​ apply.) A. Increased fibrin degradation products B. Decreased platelet count C. Shortened prothrombin time D. Elevated hemoglobin E. The presence of schistocytes

d Infants should always be placed on their​ back, or supine​ position, for sleeping until 1 year of age. Infants placed prone​ (face-down) while sleeping are at greatest risk for sudden infant death syndrome​ (SIDS). The​ side-lying, or​ fetal, position also increases the risk for SIDS

The nurse is giving discharge instructions regarding positioning for the​ client's newborn for sleeping. Which statement should the nurse​ include? A. ​"Always place your child on its tummy while​ sleeping." B. ​"Always place your child a​ side-lying position while​ sleeping." C. ​"Always place your child in a fetal position while​ sleeping." D. ​"Always place your child on its back position while​ sleeping."

b, c, d, e Actions that support the​ nurse's plan of care for the goal of preventing SIDS include providing support for smoking​ cessation, collaborating with family to create​ goals, teaching about reducing risk factors for​ SIDS, promoting a safe sleep​ environment, and encouraging breastfeeding.

The nurse is giving discharge instructions to new parents. Which instruction should be provided to promote prevention of sudden infant death syndrome​ (SIDS)? (Select all that​ apply.) A. Encourage the use of formula. B. Provide support for smoking cessation. C. Collaborate with family to create goals. D. Teach about reducing risk factors for SIDS. E. Promote a safe sleep environment.

d The focus of the investigation involves determining the cause of infant death. The investigation does not focus on parental behavior or blame for the​ infant's death. The investigation does involve the​ infant's family.

The nurse is involved in investigating the death of an infant in which sudden infant death syndrome​ (SIDS) is suspected. The nurse should expect the focus of the investigation to be on which​ factor? A. Parental behavior B. Who is to blame for the​ infant's death C. The​ infant's family D. Cause of the​ infant's death

b, c, d Pregnant clients are at risk for the development of acute DIC from the complications of​ preeclampsia, placental​ abruption, fetal​ demise, amniotic fluid​ embolism, and septic abortion. Prolonged labor and primigravida are not considered risk factors for the development of DIC.

The nurse is preparing an educational program about disseminated intravascular coagulation​ (DIC). Which condition should the nurse include as a risk factor for the development of this​ condition? (Select all that​ apply.) A. Prolonged labor B. Septic abortion C. Fetal demise D. Preeclampsia E. Primigravida

a Sips of fluids or ice chips may be used to provide moisture and relieve dryness of the mouth. Applying​ cool, not​ warm, cloths to the face and forehead may help to cool the woman involved in the intense physical exertion of pushing. The client is not encouraged to ambulate in the second stage of​ labor, but instead to rest in between pushing. The nurse and support person can assist the woman into a pushing position with each contraction to further conserve energy. Between​ contractions, the woman should be assisted into a comfortable position.

The nurse is preparing to care for a client in the second stage of labor. Which comfort measures should the nurse implement in the plan of​ care? A. Provide sips of fluids or ice chips. B. Encourage ambulation. C. Apply warm cloths to the face and forehead. D. Assist the client in maintaining a pushing position.

4. This response is correct. It is unsafe to place anything in the vagina before involution is complete.

The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

b Antepartum management for preeclampsia may include hospitalization to evaluate​ new-onset maternal and fetal conditions. There is no evidence in favor of antihypertensive medication unless maternal BP is in the severe range. Activity restriction and dietary modifications do not alter the course or outcome of preeclampsia. When at​ rest, the client may be encouraged to lie on her left side in order to maximize uterine and renal perfusion.

The nurse is providing care to a client diagnosed with preeclampsia during the antepartum period. Which information should the nurse provide to the​ client? A. ​"You will be prescribed an antihypertensive​ drug." B. ​"You may need to be​ hospitalized." C. ​"Your activity and diet will be​ restricted." D. ​"You should lie on your right side when you are​ resting."

a, b, c When implementing teaching for the prevention of​ SIDS, the nurse should include the importance of​ breastfeeding, sharing a room with the​ baby, and placing the infant on its back to sleep.​ Co-sleeping increases the risk of​ SIDS, as does having loose blankets in the​ crib, and therefore comprise inappropriate information by the nurse.

The nurse is teaching a pregnant client about the prevention of sudden infant death syndrome​ (SIDS). Which information should the nurse​ include? (Select all that​ apply.) A. ​"Place your baby on its back to​ sleep." B. ​"Breastfeed your baby if​ possible." C. ​"Share a room with your baby for the first 6​ months." D. ​"Do not tuck loose blankets under your​ baby's shoulders during​ sleep." E. ​"It is best to​ co-sleep with your​ baby."

A, C, D, E

The nurse is teaching a pregnant client regarding the risk factors related to sudden infant death syndrome​ (SIDS). Which statement by the nurse is​ appropriate? (Select all that​ apply.) A. ​"If your child is born​ premature, the risk for SIDS​ increases." B. ​"If your child is a​ girl, the risk for SIDS​ increases." C. ​"If your child shares your bed during​ sleep, the risk for SIDS​ increases." D. ​"If your child is exposed to smoke in the​ home, the risk for SIDS​ increases." E. ​"If your family has a history of​ SIDS, the risk for SIDS​ increases."

3. The woman successively changes her back from a concave to a convex posture when doing the pelvic tilt.

The nurse is teaching a woman how to do the pelvic tilt exercise. In the teaching session, which of the following should the nurse tell the woman to do? 1. Stand with the back of her heels and shoulders touching a wall. 2. Bend laterally back and forth from one side to the other. 3. Move so that her back alternately is concave and convex. 4. Lie flat on her back and move her hips from side to side.

D. Hypotension. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure. Option A: Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia; Option B is an effect of epidural anesthesia but is not the most harmful. Option C: Respiratory depression is a potentially serious complication.

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. Severe postpartum headache B. Limited perception of bladder fullness C. Increase in respiratory rate D. Hypotension

3. Cramping is an expected outcome of the administration of Methergine.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

B and C Options B and C. Research demonstrate that the occurrence of SIDS is reduced with these two positions. Options A and D: Both are inappropriate positions for infants.

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply): A. Prone. B. Side-lying. C. Supine. D. Fowler's.

1. Induction is contraindicated in transverse lie.

The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.

25 gtt/min

The physician writes the following order for a newly admitted client in labor: Begin a 1000 mL IV of D5 1/2 NS at 150 mL/hr. The IV tubing states that the drop factor is 10 gtt/mL. Please calculate the drip rate to the nearest whole. _______ gtt/min

d Strict monitoring of intake and output​ (I &​ O) is​ important, as diuresis should occur with the return of normal kidney​ function, indicating reversal of the disease process. Assessing for excessive vaginal bleeding and daily weight gain would not provide information concerning improvement of preeclampsia. The blood pressure should be monitored every 4 hours for 48​ hours, or every hour for 24 hours if on magnesium sulfate for severe preeclampsia.

The postpartum nurse is caring for a client who delivered a healthy but premature infant after induction at 35 weeks of gestation due to severe preeclampsia. Which intervention should the nurse implement postdelivery to monitor for improvement in the​ preeclampsia? A. Weighing the client daily to assess for weight gain B. Assessing for excessive vaginal bleeding C. Monitoring blood pressure every hour for the first 48 hours D. Strict monitoring of intake and output​ (I &​ O)

a, c, d, e During the client​ interview, the nurse should ask the client about the presence of preeclampsia​ complications, including​ headache, changes in​ vision, presence of nausea or​ vomiting, dizziness, and seizures. Diarrhea is not characteristic of​ preeclampsia, so this question would not be necessary to ask.

The prenatal nurse is completing an assessment of a pregnant client at 36 weeks of gestation who has preeclampsia. Which question is important for the nurse to ask during the​ assessment? (Select all that​ apply.) A. ​"Have you experienced any​ seizures?" B. ​"Have you had any episodes of​ diarrhea?" C. ​"Have you been having any nausea or​ vomiting?" D. ​"Have you noticed any changes in your​ vision?" E. ​"Have you had any​ headaches?

b, d, e Sudden infant death syndrome​ (SIDS) is the sudden death of an apparently healthy infant that remains unexplained. At​ present, SIDS is​ unpredictable, and it is impossible to prevent in some cases. Exposure to smoke is a great risk​ factor, and​ co-sleeping with infants does pose a​ risk, but sharing a room with parents does not. SIDS is a risk factor for infants who are preterm and with low birth weight and not necessarily for​ high-birth-weight infants.

The prenatal nurse is giving an informational presentation to expectant parents and includes the topic of sudden infant death syndrome​ (SIDS). Which information should the nurse​ include? (Select all that​ apply.) A. It can occur in​ high-birth-weight infants. B. It is unexpected. C. Exposure to smoke is not a factor. D. It is unpredictable. E. It can occur with​ co-sleeping infants.

FALSE. Stage 4 is 1-4 hours AFTER the delivery of the placenta. This statement describes stage 3.

True or False: Stage 4 of labor starts with the full delivery of the baby and ends with the full delivery of the placenta.* True False

FALSE: The statement should say: The umbilical cord is made up of ONE (not two) umbilical vein and TWO (not one) umbilical arteries.

True or False: The umbilical cord is made up of two umbilical veins and one umbilical artery.* True False

A. Fetal presenting part is 1 cm above the ischial spines. Station of - 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged. Options B and C: Progress of effacement is referred to by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10 cm indicating full dilation. Option D: Passage through the ischial spines with internal rotation would be indicated by a plus station, such as + 1.

Upon completion of a vaginal examination on a laboring woman, the nurse records 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines B. Effacement is 4 cm from completion C. Dilation is 50% completed D. Fetus has achieved passage through the ischial spines

4. Monitoring for rectal pressure is appropriate at this time.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

A and D. The ductus arteriosus and foramen ovale are the structures that help blood flow bypass (or shunt) away from the lungs. These structures seal off and become nonfunctional after birth. The ductus venosus plays a role with shunting blood from the LIVER (not lungs).

What structures in fetal circulation play a role in shunting blood away from the LUNGS? Select all that apply:* A. Ductus arteriosus B. Ductus venosus C. Umbilical artery D. Foramen ovale E. Umbilical vein

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 5. The nurse should assess the fetal heart before the woman ambulates.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

A. An acceleration. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A. An acceleration B. An early elevation C. A sonographic motion D. A tachycardic heart rate

3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

c, d, e All members of the healthcare team must work together to promote safety for infants to reduce the occurrence of SIDS. It is also important to include the expectant and new parents as well as the caregivers for the infant. Health and prevention should be focused on the effectiveness of​ interventions, the education of​ professionals, and utilizing traditions and cultures. Focusing on statistics or on appropriate coping mechanisms of grief is not of utmost importance when trying to educate and prevent the occurrence of SIDS.

Which factor should the nurse recognize as contributing to the prevention of sudden infant death syndrome​ (SIDS)? (Select all that​ apply.) A. Appropriate coping mechanisms of grief B. Statistics C. Effectiveness of interventions D. Education of professionals E. Traditions and cultures

4. Painless vaginal bleeding is often the only symptom of placenta previa.

Which finding should the nurse expect when assessing a client with placenta previa? 1. Severe occipital headache. 2. History of thyroid cancer. 3. Previous premature delivery. 4. Painless vaginal bleeding.

b, d To address clinical manifestations due to the increased vascular permeability of​ preeclampsia, the nurse would elevate extremities and monitor breath sounds and oxygen saturation. Reduction of external stimuli and administration of magnesium sulfate would address cerebral edema and vasospasm. Regular antenatal fetal​ surveillance/continuous intrapartum fetal monitoring would address loss of normal vasodilation of uterine arterioles.

Which intervention should the nurse implement to address clinical manifestations due to the increased vascular permeability for a client with​ preeclampsia? (Select all that​ apply.) A. Reducing external stimuli B. Monitoring breath sounds and oxygen saturation C. Providing regular antenatal fetal​ surveillance/continuous intrapartum fetal monitoring D. Elevating extremities to reduce edema E. Administering an anticonvulsant and magnesium sulfate

C. Massage the fundus every hour for the first 24 hours following birth. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Options A, B, and D are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B. Encourage the woman to void every 2 hours C. Massage the fundus every hour for the first 24 hours following birth D. Teach the woman the importance of rest and nutrition to enhance healing

B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep. Option B: Infants under 6 months may not be able to sleep for long periods because their stomachs are too small to hold adequate nourishment to take them through the night. Option A: Infants should always be placed on their backs to sleep. Research has shown a dramatic decrease in sudden infant death syndrome (SIDS) with back sleeping. Option C: Eye contact and verbal engagement with infants are important to language development. Option D: The best diet for infants under 4 months of age is breast milk or infant formula.

Which of the following actions is NOT appropriate in the care of a 2-month-old infant? A. Place the infant on her back for naps and bedtime. B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep. C. Talk to the infant frequently and make eye contact to encourage language development. D. Wait until at least 4 months to add infant cereals and strained fruits to the diet.

2. It is important to inquire about the pain level of all women in labor, but especially those from the Asian culture.

Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? 1. Apply heat to the woman's back. 2. Inquire regarding the woman's pain level. 3. Make sure that the woman's head is covered. 4. Accept the woman's loud verbalizations.

1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should receive an order to infuse Ringer's lactate before the woman is given regional anesthesia. 5. The nurse should ask the woman to empty her bladder.

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1,000 mL of Ringer's lactate. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.

1. This primigravid client—age 44 and with a history of diabetes—is very high risk for preeclampsia.

Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? 1. G1 P0000, age 44 with history of diabetes mellitus. 2. G2 P0101, age 27 with history of rheumatic fever. 3. G3 P1102, age 25 with history of scoliosis. 4. G3 P1011, age 20 with history of celiac disease.

1. Lying prone on a pillow helps to relieve some women's afterbirth pains.

Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink ice tea with lemon or lime.

1. Because a larger diameter of the fetal head is presenting to the pelvis in the LMP position, cephalopelvic disproportion is possible.

Which of the following complications of labor and delivery may develop when a baby enters the pelvis in the LMP position? 1. Cephalopelvic disproportion. 2. Placental abruption. 3. Breech presentation. 4. Acute fetal distress.

A. Vertex presentation. Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Option B: Transverse lie is an unacceptable fetal position for vaginal birth and requires a C-section. Option C: Frank breech presentation, in which the buttocks present first, can be a difficult vaginal delivery. Option D: Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis.

Which of the following fetal positions is most favorable for birth? A. Vertex presentation B. Transverse lie C. Frank breech presentation D. Posterior position of the fetal head

D. Baby Gabby who sleeps on his back. Option D: Infants who sleep on their back are least likely to develop SIDS. However, SIDS has been associated with infants who sleep on their abdomens. Options A, B, C: Being premature, having a sibling who died of SIDS, and being prenatally exposed to drugs all place the infant at high risk for developing SIDS.

Which of the following infants is least probable to develop sudden infant death syndrome (SIDS)? A. Baby Angela who was premature. B. A sibling of Baby Angie who died of SIDS. C. Baby Gabriel with prenatal drug exposure. D. Baby Gabby who sleeps on his back.

B. Massage B, massage helps relieve pain through the release of endorphins by touch.

Which of the following is most helpful during the first and second stages of labor? A. Prayers B. Massage C. Breathing techniques D. Yoga

A. Accreta Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Placenta increta leads to deep penetration of the myometrium.

Which of the following is the most common kind of placental adherence seen in pregnant women? A. Accreta B. Placenta previa C. Percreta D. Increta

1, 2, and 5 are correct. 1. Nurse midwives sometimes recommend that women at full term engage in sexual intercourse to stimulate labor. 2. Ingesting primrose oil is also sometimes recommended. Primrose oil is believed to help ripen the cervix. 5. Nipple and breast massage is sometimes recommended to help induce labor.

Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply. 1. Engage in sexual intercourse. 2. Ingest evening primrose oil. 3. Perform yoga exercises. 4. Eat raw spinach. 5. Massage the breast and nipples.

2 and 3 are correct. 2. Petechiae may develop when a client is thrombocytopenic, one of the signs of HELLP syndrome. 3. Hyperbilirubinemia develops when red blood cells hemolyze, one of the changes that may develop as a result of liver necrosis. Jaundice is a manifestation of hyperbilirubinemia.

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.

3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.

Which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the feartension- pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

b, c, d Delivery of the placenta usually takes place within 30 minutes of birth. Signs that the placenta is about to deliver include increased pain with​ contractions, lengthening of the umbilical​ cord, and a change in shape of the uterus from a disk to a globe.

Which sign is associated with the impending delivery of the​ placenta? (Select all that​ apply.) A. Change in shape of the uterus from a globe to a disk B. Lengthening of the umbilical cord C. Increased pain with contractions D. Change in shape of the uterus from a disk to a globe E. Decreased pain with contractions

C. This is the only correct statement about the ductus arteriosus. This structure connects the pulmonary artery and aorta, which helps carry mixed blood (oxygenated and deoxygenated blood) to the lower body and back to the placenta via the umbilical arteries (which branch off the descending aorta). This structure helps shunt blood away from the lungs.

Which statement below accurately describes the role of the ductus arteriosus?* A. "The ductus arteriosus helps connect the umbilical artery to the inferior vena cava." B. "The ductus arteriosus is found between the right and left atrium." C. "In fetal circulation the pulmonary artery and aorta are connected via the ductus arteriosus." D. "The ductus arteriosus only carries oxygenated blood from the left side of the heart to the right side."

a, b, d, e Fetal​ surveillance, steroid administration to accelerate fetal lung​ maturity, administration of magnesium sulfate prophylactically to prevent​ seizures, and ongoing assessment of the need for prompt delivery are all interventions that may be used during antepartum management of a client with preeclampsia. Activity and dietary restrictions do not alter the course or outcome of​ preeclampsia, so the nurse would not be implementing strategies related to this.

Which strategy should the nurse anticipate implementing during antepartum management of a pregnant client who is hospitalized at 33 weeks of gestation for preeclampsia with severe​ manifestations? (Select all that​ apply.) A. Fetal surveillance B. Ongoing assessment of the need for prompt delivery C. Activity and dietary restrictions D. Administration of magnesium sulfate E. Steroid administration

1. The relationship between the decelerations and the contractions will determine the type of deceleration pattern.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

B. Right lower quadrant. The landmark to look for when looking for PMI is the location of the fetal back in relation to the right or left side of the mother and the presentation, whether cephalic or breech. The best site is the fetal back nearest the head.

You performed Leopold's maneuver and found the following: breech presentation, fetal back at the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in which location? A. Left lower quadrant B. Right lower quadrant C. Left upper quadrant D. Right upper quadrant

A. Oozing around the IV site can indicate the patient is entering into DIC (disseminated intravascular coagulation) because clotting levels have been depleted. Therefore, the MD should be notified. Option B, C, and D are findings found in this condition, but Option A is a SEVERE complication that can develop from it.

You're performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of the following assessment findings would you immediately report to the physician?* A. Oozing around the IV site B. Tender uterus C. Hard abdomen D. Vaginal bleeding

A. This is not a normal finding. The fundus of the uterus should be firm, mid-line, and near or at the umbilicus. If the fundus is soft, boggy, and displaced, the nurse should perform fundal massage and assist the patient to the bathroom to void. A full bladder can cause the fundus to become displaced and soft/boggy.

You're performing a routine assessment on a mother post-delivery. The uterus is soft and displaced to the left of the umbilicus. What is your next nursing action?* A. Perform fundal massage and assist the patient to the bathroom. B. Continue to monitor the mother. This is a normal finding post-delivery. C. Notify the physician. D. Administer PRN dose of Pitocin as ordered by the physician.

B. This is the only correct statement. When preeclampsia occurs it is because the spiral arteries of the uterus failed to widen in diameter due to poor trophoblast invasion during the beginning of the pregnancy. Overtime, this causes problems (usually after 20 weeks gestation) and the placenta experiences ischemia. When the placenta becomes ischemic is releases substances into mom's circulation that are very toxic to her endothelial cells, which causes all the signs and symptoms seen in preeclampsia. Severity varies in patients.

You're providing an in-service to a group of new labor and delivery nurse graduates about the pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they understood how this condition develops?* A. "The basal arteries of the myometrium fail to widen to support blood flow to the placenta." B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter." C. "The cardiovascular system of the mother fails to compensate for the increased blood flow from the fetus and placental ischemia occurs." D. "If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia."

B, C, D, and F. HELLP Syndrome causes of Hemolysis of RBCs (abnormal RBC peripheral smear), Elevated Liver enzymes (>70 IU/L for AST or ALT), Low Platelets (<100,000 μL ).

Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient's lab results correlate with HELLP Syndrome?* A. Hemoglobin 12 g/dL B. Platelets 90,000 μL C. ALT 100 IU/L D. AST 90 IU/L E. Glucose 350 mg/dL F. Abnormal RBC peripheral smear

B, E, F, and G. Option A is WRONG because vaginal exams are avoided to prevent causing damage to the placenta presenting at the cervical opening. Option C is WRONG because the patient is A positive and does NOT need RhoGAM, which is for patients who are RH negative. Option D is WRONG because external monitoring should be used NOT internal, which can damage the placenta at the cervical opening.

Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A positive. What nursing interventions below will you include in the patient's care? Select all that apply:* A. Routine vaginal examinations B. Monitoring vital signs C. Administer RhoGAM per MD order D. Assess internal fetal monitoring E. Placing patient on side-lying position F. Monitoring pad count G. Monitoring CBC and clotting levels

C. Remember "SHINY" Schultze. This is the side from the baby. Try to remember the baby is shiny and new so it is the SHINY Schultze side. The Schultze mechanism is where the baby's surface is delivered first. Duncan mechanism is where the maternal side is delivered first. Remember "DULL/DIRTY" Duncan. This side will be dull/dirty, red, and rough and is the side from the mother. Try to remember the mother is dirty from labor and is in rough shape.

he mother has delivered the placenta. You note that the shiny surface of the placenta was delivered first. What delivery mechanism is this known as AND is this the maternal or baby's surface of the placenta?* A. Duncan mechanism, maternal B. Schultze mechanism, maternal C. Schultze mechanism, baby D. Duncan mechanism, baby