Nur 160 Test 1
During active labor the nurse observes the client crying during contractions and not using breathing techniques learned during prenatal classes. Which client concern is the priority for the nurse to address at this time?
altered breathing pattern Reference: Chapter 16: Labor and Delivery - Page 297
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply.
begin irregularly but become regular and predictable-felt first in lower back and sweep around to the abdomen in a wave-increase in duration, frequency, and intensity Reference: Chapter 16: Labor and Delivery - Page 293-295
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply
breast changes-amenorrhea-morning sickness Reference: Chapter 14: Before Conception, Presumptive Symptoms, p. 246.
umbilical cord testing
can be used for testing (amniocentesis) - for genetic studies (1st trimester), lung maturity (3rd trimester)
probable signs of pregnancy
chadwicks sign, goodell's sign, hegars sign positive pregnancy test
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?
crowning Reference: Chapter 16: Labor and Delivery - Page 288
2nd & 3rd trimester prenatal visit
current ultrasound visit - every 4 weeks through 28 wk, q2 wk for weeks 28-36, every week after - assess BP, weight, fetal growth, fetal HR, fetal movement, recent significant events (travel, illness, stressors) - warning signs*
Which of the following is a positive sign of pregnancy?
fetal movement felt by the examiner Reference: Chapter 14: Before Conception - Page 247
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm cervix is 100% effaced and 5 cm dilated membranes are intact and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor?
first, active Reference: Chapter 16: Labor and Delivery - Page 294-295
Bishop's scoring system
from 0-15 determines if a cervix is ready to be induced 8 or higher - likelihood of successful induction
uterine size at 12 weeks
grapefruit - uterine fundus is even with symphysis pubis
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?
head flexed forward so much that the chin touches the sternum Reference: Chapter 16: Labor and Delivery - Page 288
A nurse is putting together educational material for clients who desire to learn about how to get pregnant. Part of this information will explain that fertilization occurs:
in the fallopian tubes. Reference: Chapter 14: Before Conception - Page 244
During a routine antepartum visit a pregnant woman says "I've noticed my gums bleeding a bit since I've become pregnant. Is this normal?" The nurse bases the response on the understanding of which effect of pregnancy?
influence of estrogen and blood vessel proliferation Reference: Chapter 15: Pregnancy - Page 270
During the assessment of a woman in labor the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?
ischial spine Reference: Chapter 16: Labor and Delivery - Page 287-288
Place the following stages of labor in order from what occurs first to last. All options must be used.
latent stage-active stage-transition stage-second stage-third stageReference: Chapter 16: Labor and Delivery - Page 294-300
3rd trimester highlights
marked as increase in EST and RELAXIN - dependent edema, discomfort, BP returns to normal, urinary frequency - " i am going to be a MOM"
pulmonary changes during pregnancy
pregnancy is a state or RELATIVE RESPIRATORY ALKALOSIS - dec PaCO2 (27-35) - dec airway resistance (progesterone) - inc congestion (estrogen)
cultural humility
realizing that my intentions are good, but I am never going to be an expert on another persons culture
Affordable Care Act
requires insurances to cover pregnancies, prohibits higher premiums for women of child bearing ages, cover contraceptive care - controlled state by state
The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?
rubella Reference: Chapter 15: Pregnancy - Page 259
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.
uterine resting tone-frequency of contractions-intensity of contractions Reference: Chapter 16: Labor and Delivery - Page 302
Managing NV during Pregnancy
Ginger, vit B6 - *LOW FAT diet
Which assessment finding is most important as labor progresses?
The uterus relaxes completely between contractions. Reference: Chapter 16: Labor and Delivery - Page 286
Active phase of labor
4-7 cm, VS/FHR/toco monitor/pain assess/emotional support/education/bladder
Para (P)
# of pregnancies that resulted in delivery after 20 weeks
episodic FHR variability
not associated with contractions
The nurse is conducting an initial history and assessment on a client at 10 weeks' gestation who is pregnant with her first child. Which question is a priority for the nurse to ask the client at this time?
"Does anyone in your or the father's family have any genetic disorders?" Reference: Chapter 14: Before Conception, Health History, pp. 231-232.
A nurse is educating a prenatal client at her second visit. The client is worried about "blotchy brown spots" on her forehead. The nurse reassures the client about this change by giving which appropriate response?
"Avoid sun because it will make the discoloring darker." Reference: Chapter 15: Pregnancy - Page 271
The nurse is teaching an adolescent client about fertility and the various phases of the menstrual cycle. The client has a 28-day menstrual cycle. Which statement is a priority for the nurse to include in the teaching?
"Day 14 of your menstrual cycle is normally when you will ovulate." Reference: Chapter 14: Before Conception - Page 243
Which question would be most important for a nurse to ask a G2P1 client who has a child with sickle cell anemia?
"Did you and your partner get genetic testing? "Reference: Chapter 14: Before Conception - Page 238
During a physical assessment the nurse palpates a pregnant client's fundus at the level of the umbilicus. What statement should the nurse make to the client about this assessment finding?
"You are at 20 weeks of your pregnancy." Reference: Chapter 15: Pregnancy - Page 264
after 20 weeks, determine uterine placement
# of cm from symphysis to fundus = # of weeks gestation (approx)
Gravida (G)
# of pregnancies the patient has had (including the current one)
A mother comes in with her 17-year-old daughter to find out why she has not had a menstrual cycle for a few months. Examination confirms the daughter is pregnant with a fundal height of approximately 24 cm. The nurse interprets this finding as indicating that the daughter is approximately how many weeks pregnant?
24 Reference: Chapter 15: Pregnancy - Page 280
The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding?
50% effaced. Reference: Chapter 16: Labor and Delivery - Page 296
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?
Acceleration of at least 15 bpm for 15 seconds Reference: Chapter 16: Labor and Delivery - Page 306
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman. Reference: Chapter 16: Labor and Delivery - Page 310
As a woman enters the second stage of labor her membranes spontaneously rupture. When this occurs what would the nurse do next?
Assess fetal heart rate for fetal safety. Reference: Chapter 16: Labor and Delivery - Page 294
A client has just had an epidural placed. Before the procedure her vital signs were as follows: BP 120/70 P90 bmp R18 per min and O2 sat 98%. Now 3 minutes after the procedure the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40 P100 bmp R20 per min and O2 sat 96%. Which interventions should the nurse perform?
Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Reference: Chapter 16: Labor and Delivery - Page 315-316
A nurse is teaching a group of primigravida women who are in their first trimester. One of the women asks the nurse about sexual activity during pregnancy. Which information would the nurse most likely incorporate into the response?
Because of pelvic congestion, women may experience increased clitoral sensitivity. Reference: Chapter 15: Pregnancy - Page 265
The nurse is caring for a client entering the active phase of labor. Which outcome is most appropriate at this time?
Client will adjust body to attain the most comfortable position. Reference: Chapter 16: Labor and Delivery - Page 296
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?
Continue to monitor the client and the fetal heart rate.. Reference: Chapter 16: Labor and Delivery - Page 306
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate?
Document this and continue to monitor the murmur at future visits. Reference: Chapter 15: Pregnancy - Page 263
The nurse is assessing a young female who just found out she is pregnant. She is now reporting vague abdominal discomfort. After noting the client has a history of PID the nurse predicts the health care provider will give priority to ruling out which situation?
Ectopic pregnancy Reference: Chapter 15: Pregnancy - Page 277
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy excited and confident to introverted and restless. Assessment reveals heart rate 100 blood pressure 137/85 mm Hg and hyperventilation. EFM reveals no variability for almost 20 minutes then evident variability with no late decelerations. Which action should the nurse prioritize?
Help the client regain control of her breathing technique. Reference: Chapter 16: Labor and Delivery - Page 297
To assess the sociocultural aspects of the family of an adolescent in an ambulatory clinic about which of the following would you ask?
His family structure Reference: Chapter 14: Before Conception, Family Context, p. 226.
A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn? Select all that apply.
Limit consumption of food before bedtime-Sleep in a semi-Fowler position-Avoid overeating. Reference: Chapter 15: Pregnancy - Page 270
A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Reference: Chapter 16: Labor and Delivery - Page 316
A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?
Perform Kegel exercises. Reference: Chapter 15: Pregnancy - Page 269
Progesterone
RELAXES SMOOTH MUSCLE
A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?
Reassuring; it is associated with normal acid-base balance. Reference: Chapter 16: Labor and Delivery - Page 311
The nurse is obtaining a fetal nonstress test and having difficulty maintaining the fetal heart rate. What nursing action is most helpful?
Recline the client backward. Reference: Chapter 15: Pregnancy - Page 279
During a routine prenatal visit a pregnant woman reports a white thick vaginal discharge. She denies any itching or irritation. Which action would the nurse take next?
Tell the woman that this is entirely normal. Reference: Chapter 15: Pregnancy - Page 269
During a physical exam the physician noted that the pregnant client has a positive Chadwick sign. What client findings would be noted for this symptom?
The cervix has a bluish, purple discoloration. Reference: Chapter 14: Before Conception - Page 247
The nurse is caring for a client who desires to become pregnant within a few months. Which outcome regarding folic acid intake would be appropriate for this client?
The client will begin taking 400 μg of folic acid every day. Reference: Chapter 14: Before Conception - Page 232
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
The client's cervix is fully dilated. Reference: Chapter 16: Labor and Delivery - Page 297
The student nurse cares for a child from a large extended family. Considering the child's family structure which way might the child view the student nurse as "poor"?
The student is unmarried and lives alone. Reference: Chapter 14: Before Conception, Family Context, pp. 226-227
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?
The uterus contracts and squeezes the cord against the fetus. Reference: Chapter 15: Pregnancy - Page 259-260
A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line which nursing action is best?
Use distraction therapy. Reference: Chapter 16: Labor and Delivery - Page 318 - 319
Which method does the nurse use to determine fetal presentation position and attitude?
Utilize Leopold maneuvers. Reference: Chapter 16: Labor and Delivery - Page 296
periodic FHR variability
associated with uterine contractions
Ethnocentricity
belief that one's own ethnic group or culture is superior to that of others
Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth. The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?
between 24 and 28 weeks' gestation Reference: Chapter 15: Pregnancy - Page 278
When applying the ultrasound transducer for continuous external electronic fetal monitoring the nurse would place the transducer at which location on the client's body to record the FHR?
between the umbilicus and the symphysis pubis Reference: Chapter 16: Labor and Delivery - Page 302
key components of health hx
chronic diseases (htn), substance use, vaccinations, wt and nutrition, environmental exposures, infections, social
Patterned breathing techniques used in labor provide which benefits? Select all that apply.
conscious relaxation-distraction-pain relief without special tools Reference: Chapter 16: Labor and Delivery - Page 319
false labor
contractions are irregular, cervix has little effacement or dilation, posterior position, fetus not engaged
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?
decreased alertness Reference: Chapter 16: Labor and Delivery - Page 316
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?
dilation (dilatation) of cervix diameter to 10 cm Reference: Chapter 16: Labor and Delivery - Page 297
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency which pattern would the nurse anticipate seeing on the monitor?
fetal heart rate declining late with contractions and remaining depressed Reference: Chapter 16: Labor and Delivery - Page 307
A nurse is caring for a client in her fourth stage of labor. Which nursing action(s) is essential during the fourth stage of labor? Select all that apply.
fundal assessment every 15 minutes and assessment of bleeding for expulsion of placental fragments Reference: Chapter 16: Labor and Delivery - Page 300-302
advanced maternal age (> 35)
inc risk for fetal abnormalities, miscarriage, hypertension, complications during delivery
Amnioinfusion
injection of NS into uterus to help cushion baby - resting tone > 15mmHg, turn off and reassess.
positive signs of pregnancy
irrefutable findings (ex- seeing baby on ultrasound), fetal heart rate
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side the small parts toward the right side and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant. Reference: Chapter 16: Labor and Delivery - Page 302
different family structures
nuclear family, same sex parents, single parents, blended families
ovulation
occurs 14 days after start of LNMP ovum in fallopium tubs approx 3 days
Interpretation of FHR - Category 1
predicts normal acid base balance baseline 110-160 bpm early decelerations (present or absent) accelerations (present or absent)
Early in pregnancy frequent urination results mainly from which of the following?
pressure on the bladder from the uterus Reference: Chapter 15: Pregnancy - Page 266
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?
shoulder Reference: Chapter 16: Labor and Delivery - Page 289 - 291
A pregnant client is visiting the clinic and complains about the tiny blanched slightly raised end arterioles on her face neck arms and chest. The nurse should explain that these are normal during pregnancy and are referred to as:
telangiectasias. Reference: Chapter 15: Pregnancy - Page 261
Tachysystole
usually d/t oxytocin more than 5 contractions in 10 mins
The nurse is caring for a woman who has entered the second stage of labor. Which action by the woman would the nurse correct?
holding breath during pushing Reference: Chapter 16: Labor and Delivery, p. 315.
An anatomy professor is teaching a class of pre-nursing students about the female reproductive system. One student asks "Where is the opening to the vagina?" The best answer the professor can give is:
in what is called the vestibule, which is located between the labia minora. Reference: Chapter 14: Before Conception, p. 240.
A pregnant woman who had stress incontinence during a previous pregnancy asks the nurse what could be done to manage this in her current pregnancy. What should the nurse recommend to the client?
Kegel exercises Reference: Chapter 15: Pregnancy - Page 269
A pregnant woman tends not to eat for long periods of time because of her busy work schedule. What process safeguards her fetus from becoming hypoglycemic during this time?
Somatomammotropin helps to regulate glucose levels. Reference: Chapter 15: Pregnancy - Page 259
3rd trimester
TDAP offered to provide immunity
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.
Turn the client on her left side-Administer oxygen by mask-Assess client for underlying causes. Reference: Chapter 16: Labor and Delivery - Page 313
Naegele's Rule
add 7 days to LMP, subtract 3 months, add 1 year
Which nursing action has a negative effect on fetal descent?
administering opioid pain medication Reference: Chapter 16: Labor and Delivery - Page 312-313
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?
administration of oxygen by mask Reference: Chapter 16: Labor and Delivery - Page 304
human chorionic gonadotropin (hCG)
possibly the reason for NV in the 1st trimester - levels double almost every day in 1st trimester - highest in morning
The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions?
the interval between the beginning and the end of one contraction Reference: Chapter 16: Labor and Delivery - Page 286
Implantation generally occurs at which place on the uterus?
the upper posterior surface Reference: Chapter 15: Pregnancy - Page 252
1st trimester highlights
uterus still a pelvic organ, inc urinary frequency, common physical changes, relatively unchanged VS - "I am pregnant"
Group B Streptococcus (GBS)
vaginal and rectal swab at 36 weeks mom will need 2 doses of antibiotics before delivery
uterine size at 20 weeks
- fundus is palpable at umbilicus - about 20 cm from the top rum of symphysis pubis
Latent phase of labor
0-3 cm dilation, anxious and excited, ambulate
A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?n
Before reporting to the RN, determine the uterine contraction pattern. Reference: Chapter 16: Labor and Delivery - Page 303
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?
The mother may have difficulty working effectively with contractions. Reference: Chapter 16: Labor and Delivery, Psyche, p. 291.
Which body system is most affected throughout the embryonic and fetal period by teratogens?
central nervous system,central nervous system Reference: Chapter 14: Before Conception - Page 236-237
A group of nursing students are preparing a presentation for a health fair illustrating what happens to the body during pregnancy. Which structure will the students point out is influenced the most by hormones to prepare for conception?
endometrium Reference: Chapter 14: Before Conception - Page 239, 242
A client is trying to have a baby and wants to know the best time to have intercourse to increase the chances of pregnancy. Which time for intercourse is ideal to help her chances of conceiving?
one or two days before ovulation Reference: Chapter 14: Before Conception - Page 243
sperm + ovum =
single ZYGOTE with 46 chromosomes
Which of these cardiac variations if found in the client who is pregnant should the nurse recognize as a normal finding in pregnancy?
soft systolic murmur Reference: Chapter 15: Pregnancy - Page 263
A woman comes in for her annual gynecological examination and informs the nurse that she is going to try and become pregnant. She asks the nurse when the best time in the month is to become pregnant. What is the best response by the nurse?
"3 days before until 2 days after ovulation." Reference: Chapter 14: Before Conception - Page 244
The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best?
"At 36 weeks' gestation, the fundus is in the normal expected location." Reference: Chapter 15: Pregnancy - Page 264
A primigravida who is 40 weeks' pregnant thinks she may be in labor. She calls the nurse and reports that she has had 10 contractions in the last hour. She says that they are mildly painful and last 45 seconds. What is the best response from the nurse ?
"Did your water break? Do you feel the baby moving?" Reference: Chapter 16: Labor and Delivery - Page 295
A primigravida who is 40 weeks' pregnant thinks she may be in labor. She calls the nurse and reports that she has had 10 contractions in the last hour. She says that they are mildly painful and last 45 seconds. What is the best response from the nurse?
"Did your water break? Do you feel the baby moving?" Reference: Chapter 16: Labor and Delivery - Page 295
The nurse is concerned that a pregnant client is not adjusting emotionally to being pregnant. Which statement indicates that the client may need additional counseling?
"I need to get right back to work after delivery." Reference: Chapter 15: Pregnancy - Page 275-276
The nurse is seeing a client who is going to be married in a month. This client has a history of Huntington disease in her family. The genetic testing has come back and the client has just been told she carries the gene for Huntington disease and will develop the disease when she gets older. The client asks the nurse if this information is confidential and if it will remain that way. The nurse explains to the client that her family should be told and so should her fiancé. The client forcefully tells the nurse "no." She is not going to tell either her family or her fiancé. What is the nurse's best response?
"I will respect your wishes and keep your information confidential. I do wish you would reconsider though." Reference: Chapter 14: Before Conception - Page 231
When collecting data to devise a labor plan for a multiparous woman which question best allows the nurse to develop individualized strategies?
"Tell me how you handled labor pain in your past deliveries." Reference: Chapter 16: Labor and Delivery - Page 311
A primigravida client at 38 weeks' gestation calls the clinic and reports "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." Reference: Chapter 16: Labor and Delivery - Page 294
The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus?
"The gloves they provide irritate my hands, so I don't use them." Reference: Chapter 15: Pregnancy - Page 275
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process the nurse should point out "0 station" refers to which sign?
"The presenting part is at the true pelvis and is engaged." Reference: Chapter 16: Labor and Delivery - Page 288
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?
+4 Reference: Chapter 16: Labor and Delivery - Page 288
FHR decelerations
- early (during contraction d/t head compression) - late (after contraction d/t fetal reflex from hypoxia) - variable (abrupt decrease, d/t transient compression of umbilical blood vessels) - late and variable, intervene with nonrebreather and LR bolus, maternal position change
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
-2 station. Reference: Chapter 16: Labor and Delivery - Page 288
implantation
6-10 days spotting** corpus luteum produces progesterone
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable nauseated annoyed and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8 to 10 Reference: Chapter 16: Labor and Delivery - Page 297
Transitional phase of labor
8-10 cm, dilated with strong contractions, needs support, effacement up to 100%, SROM, restless/fear - VS/FHR/toco/pain assess/emotional/bladder
A client who is 16 weeks pregnant has a lower blood pressure than that of prepregnancy levels. What should the nurse realize as being the cause for this lower blood pressure?
A decrease in the second trimester may occur because of placental growth. Reference: Chapter 15: Pregnancy - Page 263
The first stage of labor is often a time of introspection. In light of this which information would guide the nurse's plan of care?
A woman may spend time thinking about what is happening to her. Reference: Chapter 16: Labor and Delivery - Page 294-297
A client asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which statement should the nurse expect to include in the client's teaching plan?
As ovulation approaches, cervical mucus is abundant and stretchable. Reference: Chapter 14: Before Conception - Page 243
You see a 3-year-old girl in an ambulatory clinic because she has a bad cold. Her mother tells you the girl's problem was caused by her being affected by "mal ojo." Which of the following would be the best action?
Ask her mother what symptoms her daughter is experiencing Reference: Chapter 14: Before Conception - Page 226
During an admission assessment of a client in labor the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?
Assess the amount of cervical dilation (dilatation). Reference: Chapter 16: Labor and Delivery - Page 296
A antepartum client learns that the fetus has a genetic anomaly that will affect cognitive and musculoskeletal development. The client is discussing this with the spouse and the nurse. The client and spouse want to know what options are available to them. What is the first thing that the nurse needs to do to help this couple with decision making?
Assist the couple in identifying their values. Reference: Chapter 15: Pregnancy - Page 226
During which time is the nurse correct to document the end of the third stage of labor?
At the time of placental delivery Reference: Chapter 16: Labor and Delivery, Third Stage, p. 300.
The nurse is teaching a pregnant client in her last trimester about interventions to help reduce risks of complications during pregnancy. Which of the following are recommended guidelines?
During the last month, rest on the left side for at least an hour, morning and afternoon. Reference: Chapter 15: Pregnancy - Page 267
A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply.
Establish a baseline of present health-Determine the gestational age of the fetus-Monitor for fetal development and maternal well-being-Identify women at risk for complications. Reference: Chapter 15: Pregnancy - Page 272
A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?
Fetal movement felt by examiner Reference: Chapter 14: Before Conception - Page 246
The nurse is assessing a 16-year-old female on a routine well-child visit. Which assessment finding will the nurse predict this healthy female will report concerning her menstrual cycles?
Flow usually lasts 4 to 6 days. Reference: Chapter 14: Before Conception - Page 243
A nursing instructor is explaining the stages of fetal development to a group of nursing students. The instructor determines the session is successful after the students correctly choose which time period as representing the pre-embryonic stage?
From fertilization to the end of the second week after fertilization Reference: Chapter 15: Pregnancy - Page 256
A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history?
G3 P0020 Reference: Chapter 14: Before Conception - Page 233
FHR accelerations
GOOD; Abrupt increase of at least 15 BPM from the baseline; onset to peak is less than 30 seconds; lasts at least 15 seconds but no more than 2 minutes; associated with normal oxygenation
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out "The baby is coming!"?
Inspect the perineum. Reference: Chapter 16: Labor and Delivery, p. 299
The nurse is reviewing the functions of the ovaries uterus clitoris and vagina with a group of nursing students. What would be the best response by a nursing student about the function of the uterus?
It receives the fertilized ovum and provides housing and nourishment for a fetus. Reference: Chapter 14: Before Conception - Page 239
A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?
Occiput posterior position Reference: Chapter 16: Labor and Delivery - Page 312
The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?
Positive home pregnancy test Reference: Chapter 14: Before Conception - Page 246
A client has presented in the early phase of labor experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?
Practicing effleurage on the abdomen Reference: Chapter 16: Labor and Delivery - Page 318
Interpretation of FHR - Category 3
Predicts ABNORMAL acid base includes either... absent baseline FHR variability AND - recurrent late decelerations (BAD- placental insufficiency) - recurrent variable decels (amnioinfusion didnt work) - bradycardia (consistent) - running back to OR
A nurse is caring for a client in her second trimester of pregnancy. During a regular follow-up visit the client reports varicosities of the legs. Which instruction should the nurse provide to help the client alleviate varicosities of the legs?
Refrain from crossing legs when sitting for long periods. Reference: Chapter 15: Pregnancy - Page 268
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status Reference: Chapter 16: Labor and Delivery, The Pharmacy 16.1, p. 314.
During a yearly gynecologist appointment a woman tells the nurse that she and her spouse hope to become pregnant soon. In reviewing the client's current health status what will the nurse recommend to this client for a healthy pregnancy? Select all that apply.
Stop smoking immediately-Eat a healthy diet with fruits and vegetables-Avoid all alcohol intake. Reference: Chapter 15: Pregnancy - Page 276
The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage?
Stretching and breathing exercises such as yoga Reference: Chapter 15: Pregnancy - Page 275
A primigravida client has come to the clinic for a prenatal checkup. What teaching topics would help to promote a healthy pregnancy for this client?
Swimming in a pool is a recommended exercise during pregnancy. Reference: Chapter 15: Pregnancy - Page 275
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department which nursing action is best?
Take no extra measures; prepare for a standard labor. Reference: Chapter 16: Labor and Delivery - Page 286
A recently married couple come to the prenatal clinic because they are concerned about genetic testing. The husband is of Jewish heritage. The nurse should recommend the couple undergo genetic testing to determine if the fetus has which disorder common among Ashkenazi Jews (Jews of Eastern European lineage)?
Tay-Sachs disease Reference: Chapter 14: Before Conception - Page 238
A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next?
Tell the client these are normal findings during pregnancy. Reference: Chapter 15: Pregnancy - Page 265
The nurse-midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell sign. Which description illustrates this alteration?
The cervix softens. Reference: Chapter 15: Pregnancy - Page 265
When planning a labor experience for a primigravid understanding which characteristic of labor pain is most helpful?
The characteristics of labor pain follow a pattern. Reference: Chapter 16: Labor and Delivery - Page 312
The nurse has identified the diagnosis of imbalanced nutrition for a pregnant client. Which assessment data did the nurse use to identify this diagnosis for the client?
The client does not want to gain any weight while pregnant. Reference: Chapter 15: Pregnancy - Page 274
Which statement best expresses the role of the corpus luteum?
The corpus luteum secretes progesterone to promote the preparation of the endometrium for implantation. Reference: Chapter 14: Before Conception, Female Reproductive Hormones, p. 241.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?
The fetus is in the true pelvis and engaged. Reference: Chapter 16: Labor and Delivery - Page 288
A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group the nurse determines that the teaching was successful based on which statement by the group?
The pelvic outlet is associated with the true pelvis. Reference: Chapter 16: Labor and Delivery - Page 286
The nurse is reviewing the functions of the ovaries uterus clitoris and vagina with a group of nursing students. What would be the correct response by a nursing student about the function of the ovaries?
They produce female gametes or ova and secrete female sex hormones. Reference: Chapter 14: Before Conception - Page 239
Which reason explains why women should be encouraged to perform Kegel exercises after delivery?
They promote blood flow, enabling healing and muscle strengthening. Reference: Chapter 15: Pregnancy - Page 269
The nurse is caring for a client who prefers resting on her back during the labor process. To facilitate client wishes which nursing action is required?
Utilize a wedge under one hip Reference: Chapter 16: Labor and Delivery - Page 296
Which procedure is contraindicated in an antepartum client with bright red painless bleeding?
Vaginal examination Reference: Chapter 16: Labor and Delivery - Page 296
Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.
Vaginal rugae stretch and smooth out. The cervix dilates to 10 cm. The cervix softens. Reference: Chapter 16: Labor and Delivery - Page 284,286
The nurse is explaining the phases of the uterine cycle to a client. What action during the proliferative phase of the uterine cycle should the nurse include in the teaching session with the client?
While the ovarian follicles are producing increased amounts of estrogen, the endometrium prepares for possible fertilization with pronounced growth. Reference: Chapter 14: Before Conception - Page 243
The nursing instructor has finished leading a general discussion with a group of nursing students exploring the labor and birthing process. The instructor determines the session is successful when the students correctly state which goal should be a priority?
Work with the labor client to plan pain management options. Reference: Chapter 16: Labor and Delivery - Page 311-312
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?
allowing the woman time to be alone Reference: Chapter 16: Labor and Delivery - Page 296-297
When a woman is admitted to the labor and delivery unit her husband says he is going to work and asks you to call when the baby is born. Your best response to this husband would be to:
ask him if he knows that he can stay with his wife during labor. Reference: Chapter 14: Before Conception - Page 226
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
backache-lightening-bloody show Reference: Chapter 16: Labor and Delivery - Page 293-294
umbilical cord
connects baby to placenta, 2 arteries 1 vein - a = deoxygenated blood/ v=oxygenated - Wharton's jelly
true labor
contractions are regular, stronger, longer, and closer together - cervix = effaced, dilated, moves to anterior positioning, bloody shows - fetus - engaged, presses on bladder
supine hypotension
do NOT allow mom to lie flat on her back - uterus presses down on inferior vena cava
When teaching a group of nursing students about the stages of labor the nurse explains that softening thinning and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?
effacement Reference: Chapter 16: Labor and Delivery, Primary Powers, p. 285.
A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain?
effleurage Reference: Chapter 16: Labor and Delivery - Page 319
The nurse is caring for a client who has a retroverted uterus. The nurse would explain that this means her:
entire uterus is tipped backward.Reference: Chapter 15: Pregnancy - Page 277
A school nurse who is teaching a health course at the local high school is presenting information on human development and sexuality. When talking about the role of hormones in sexual development which hormone does the nurse teach the class is the most important for developing and maintaining the female reproductive organs?
estrogen Reference: Chapter 14: Before Conception - Page 242
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part with the legs extended upward. The nurse identifies this as which type of breech presentation?
frank Reference: Chapter 16: Labor and Delivery - Page 290
placental function
gas exchange, excretion of urine, nutrition, storage, hormone production
Which nursing action is required before a client in labor receives an epidural?
giving a fluid bolus of 500 ml Reference: Chapter 16: Labor and Delivery - Page 315
A nurse is preparing a program for a group of parents of prepubertal children about the changes to expect with puberty. When describing the sequence of events that occur the nurse would identify which hormone as initiating the cycle?
gonadotropin-releasing hormone Reference: Chapter 14: Before Conception - Page 241
2nd trimester highlights
inc in PRO, related assessment findings/common complaints, uterus now in abdomen, BP drops 5-10 mmHg - "I am going to have a baby"
Interpretation of FHR - Category 2
includes all tracing NOT categorized as 1 or 3 - INTERMEDIATE = not predictive acid base balance - warrant eval, surveillance, and reevaluation
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?
increased risk of infection Reference: Chapter 16: Labor and Delivery - Page 294
The nursing instructor is presenting the basic physiologic changes in the woman that can occur during a pregnancy. The instructor determines the session is successful when the students correctly choose which change in the respiratory function during pregnancy as normal?
increased tidal volume Reference: Chapter 15: Pregnancy - Page 262
A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply.
latent-active-transition Reference: Chapter 16: Labor and Delivery - Page 294
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding?
less anxiety Reference: Chapter 16: Labor and Delivery - Page 314
A woman is taking vaginal progesterone suppositories during her first trimester because her body does not produce enough of it naturally. She asks the nurse what function this hormone has in her pregnancy. What should the nurse explain is the primary function of progesterone?
maintains the endometrial lining of the uterus during pregnancy Reference: Chapter 15: Pregnancy - Page 252
1st Prenatal visit
medical, OB, travel hx - psychosocial hx (depression? IPV?) - calculate due date (ultrasound if unsure of LNMP) - complete physical exam (inc pelciv and uterine size) - flu vaccine oct-mar - labs (blood type and cross, H&H, PAP smear, gonorrhea and chlamydia screen, C&S
quickening
mom feels fetal movement at about 20 weeks primigravidas - multigravidas will feel before 20 weeks
pregnant adolescents
more at risk for preeclampsia, preterm birth, fetal growth restriction, infant death, instrumental deliveries, postpartum depression, intimate partner violence
preconceptual care
more important to preventing congenital anomalies (birth defects) than early prenatal care!
A nurse is conducting a class with group of pregnant women who are all in their first trimester of pregnancy. During the class the women are discussing the various discomforts that they are experiencing. The nurse would expect to hear reports about which discomforts? Select all that apply.
nausea-urinary frequency-breast tenderness Reference: Chapter 15: Pregnancy - Page 268-269
The nurse is teaching a pregnant woman about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as being released when the newborn sucks at the breast?
oxytocin Reference: Chapter 15: Pregnancy - Page 262
The five "Ps" of labor are:
passageway, passenger, position, powers, psych.Reference: Chapter 16: Labor and Delivery - Page 284-291
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as:
pica. Reference: Chapter 15: Pregnancy - Page 270
A nurse is providing care to a woman who has just found out that she is pregnant. The nurse is describing the events that have occurred and the structures that are forming. When describing the trophoblast to the client the nurse would explain that this structure forms:
placenta. Reference: Chapter 15: Pregnancy - Page 251-252
While discussing labor with a client and her partner the nurse is asked what the best position is for giving birth to the baby. The nurse provides them with information that indicates research has shown which position as the best?
position of comfort for the mother Reference: Chapter 16: Labor and Delivery - Page 291
During the initial prenatal visit the nurse performs what assessment to guide teaching about nutrition during pregnancy?
prepregnancy BMI Reference: Chapter 15: Pregnancy - Page 274
A pregnant client in her second trimester visits a health care center. She informs the nurse that at times she experiences difficulty breathing. What would the nurse identify as the most likely cause of the client's report?
pressure on the diaphragm by the growing fetus Reference: Chapter 15: Pregnancy - Page 262
Assessment for surfactant level is a primary estimation of fetal maturity. The purpose of surfactant is to:
prevent alveoli from collapsing on expiration. Reference: Chapter 15: Pregnancy - Page 257
The nurse is assessing a woman who is pregnant for the first time. Which of the following terms applies to this client?
primigravida Reference: Chapter 14: Before Conception - Page 232
A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears the nurse should mention the role of the hormone that softens the cervix and collagen in the joints which allows dilation (dilatation) and enlargement of the birth canal. What is this hormone?
relaxin Reference: Chapter 15: Pregnancy - Page 259
The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?
rupture of membranes Reference: Chapter 16: Labor and Delivery - Page 303
A client comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is in which of the following stages of labor ?
second stage Reference: Chapter 16: Labor and Delivery - Page 297-298
After teaching a class on the female reproductive system the nurse determines that the teaching was successful when the class identifies which action as the primary function of the ovaries?
secreting estrogen and progesterone Reference: Chapter 14: Before Conception - Page 239
A client is concerned about the mercury levels in fish and asks the nurse which fish are safe to eat. The best response is:
shrimp, canned tuna, pollack, and catfish. Reference: Chapter 15: Pregnancy - Page 274
presumptive signs of pregnancy
subjective, reported by patient, could have causes the than pregnancy
umbilical cord functions
temperature maintenance, cushioning, oral fluids, facilitates movement
A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:
the buttocks are presenting first with both legs extended up toward the face. Reference: Chapter 16: Labor and Delivery - Page 290
The nurse is assisting a primigravida on calculating the due date of her baby using Naegele rule. The most important information provided by the mother is:
the first day of the last menstrual period. Reference: Chapter 15: Pregnancy - Page 253-254
A school nurse is talking to an adolescent who asks about why she has monthly menstrual cycles. The best explanation that the nurse can offer regarding the menstrual phase is to tell her that:
the uterine lining is being shed due to lowering of hormone levels. Reference: Chapter 14: Before Conception - Page 242
A number of inherited diseases can be detected in utero by amniocentesis. Which disease can be detected by this method?
trisomy 21 (Down syndrome) Reference: Chapter 15: Pregnancy - Page 279
A woman has a positive pregnancy test and comes to the nurse with left lower quadrant pain. Bimanual examination reveals a tender mass. Which of the following is suspected?
tubal pregnancy Reference: Chapter 15: Pregnancy - Page 277
Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply.
walking with partner support-straddling with forward leaning over a chair-rocking back and forth with foot on chair Reference: Chapter 16: Labor and Delivery - Page 293
A nurse is reviewing the medical records of several pregnant women who have come to the center for care. Which woman would the nurse most likely identify as being at highest risk for nutritional deficiency during pregnancy?
woman with a 1-year-old infant Reference: Chapter 14: Before Conception - Page 236-237
The nurse is planning care for several pregnant clients. Which client is at the highest risk for nutritional deficiency while pregnant?
woman with a 1-year-old infant Reference: Chapter 15: Pregnancy - Page 270