Nur 160 Test 1
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? 1. Premature Ventricular contractions 2. S4 (atrial gallop) 3. Split S1S2 4. Soft systolic murmur
4. Soft systolic murmur Explanation: A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by the nurse.
Which hormone(s) is secreted by the placenta during the pregnancy? Select all that apply. 1. Prolactin 2. Estrogen 3. Testosterone 4. Progesterone 5. Human Chorionic Gonadotropin
2. Estrogen 4. Progesterone 5. Human Chorionic Gonadotropin Explanation: The placenta secretes hormones that help to sustain the pregnancy. These include progesterone, estrogen, human placental lactogen, and human chorionic gonadotropin. Testosterone is secreted by the male testes. Prolactin is secreted by the anterior pituitary gland.
During pregnancy most nutritional needs can be consumed in adequate amounts through the diet. Which nutrient is the exception to this statement? 1. Sodium 2. Iron 3. Vitamin D 4. Calcium
2. Iron Explanation: Although most nutrients are needed in greater amounts during pregnancy, most women who are at low nutritional risk can meet their nutrient needs throughout pregnancy from food alone. A notable exception is iron. Folic acid is another possible exception. As previously noted, fortified foods or supplements containing 600 micrograms of folic acid are recommended during pregnancy. A woman at low nutritional risk can meet the needs for calcium, sodium, and vitamin D in her diet.
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: 1. Zygote 2. Placental 3. Morula 4. Fetal membrane
2. Placenta Explanation: The trophoblast forms the placenta and chorion. The blastocyst forms the embryo and amnion. The zygote is formed from the union of the sperm and ovum. The morula is a mass of 16 cells that develop as cleavage cell division continues after fertilization.
To prevent exposure to hepatitis A virus, the nurse teaches the pregnant client to avoid which food? 1. Grilled tuna 2. Raw fish 3. Undercooked chicken 4. Raw eggs
2. Raw fish Explanation: The hepatitis A virus is found in raw fish. Raw eggs and undercooked chicken can transmit salmonella, and swordfish can contain high levels of mercury.
The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? 1. Face 2. Shoulder 3. Buttocks 4. Occiput
3. Buttocks Explanation: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation.
When documenting the fetus is at 0 station, the nurse knows this is where in relation to the pelvic structure? 1. ischial spines 2. pelvic inlet 3. pelvic outlet 4. pelvic crest
1. ischial spines During the cervical check for fetal station, 0 station is the engagement of the fetus at the level of the ischial spines of the pelvis. The ischial spines are a landmark that is used mark the passage of the fetus. The pelvic crest is a landmark location on the pelvis for documenting fetal station. The pelvic inlet must be shaped accordingly to allow for passage of the fetus. The pelvic outlet is associated with internal rotation of the fetal head.
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? 1. Promptly inform the primary care provider. 2. Advocate for the client to have a vaginal examination. 3. Continue to monitor the client and the fetal heart rate.. 4. Reposition the client.
3. Continue to monitor the client and the fetal heart rate.. As long as baseline remains within normal limits and the variability is good, early decelerations are benign and no further action is necessary.
A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: 1. A congenital defect 2. Prolonged labor 3. Cranial bones overlapping at the suture line 4. Extreme pressure in the vaginal vault
3. Cranial bones overlapping at the suture line Explanation: This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor.
A client in her second trimester arrives at a health care facility for a follow-up visit. During the exam, the client reports constipation. Which instruction should the nurse offer to help alleviate constipation? 1. Practice Kegel exercises 2. Avoid spicy or greasy foods in meals 3. Ensure adequate hydration and bulk in the diet 4. Avoid lying down for 2 hours after meals
3. Ensure adequate hydration and bulk in the diet Explanation: To help alleviate constipation, the nurse should instruct the client to ensure adequate hydration and bulk in the diet. The nurse should instruct the client to avoid spicy or greasy foods when a client complains of heartburn or indigestion. The nurse also should instruct the client to avoid lying down for 2 hours after meals if the client experiences heartburn or indigestion. The nurse should instruct the client to practice Kegel exercises when the client experiences urinary frequency.
When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being? 1. The fetus descends further into the birth canal 2. There is an increase in fetal movement 3. Fetal heart rate acceleration occurs 4. Fetal heart rate deceleration occurs
3. Fetal heart rate acceleration occurs Explanation: The fetus is stimulated via an acoustic vibrator. From the stimulation, the fetal heart rate accelerates. If the acceleration occurs, fetal acidosis is not present. Fetal movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal.
A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? 1. regional anesthesia 2. local infiltration 3. General anesthesia 4. epidural block
3. General anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.
A client presents at the emergency department. During the assessment, the nurse notes the following: Client is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C (100.9°F). The client is diagnosed with pyelonephritis. What would be the treatment of choice? 1. Hospitalization and intravenous antibiotics 2. Oral antibiotics and bed rest at home 3. Hospitalization and intravenous hydration 4. Home care and oral hydration and antibiotics
1. Hospitalization and intravenous antibiotics Explanation: Pyelonephritis can develop when a urinary tract infection (UTI) is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, characterized by severe flank pain and a fever above 100.4°F (38°C). While pyelonephritis is often treated on an outpatient basis for nonpregnant clients, during pregnancy, pyelonephritis requires intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal.
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? 1. Massage the woman's back. 2. Encourage the woman to rest between contractions. 3. Change the woman's position. 4. Give the prescribed medication.
1. Massage the woman's back. Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted.
A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. 1. Membrane status 2. Current pregnancy history 3. Support system 4. Estimated date of birth 5. Fundal height measurement 6. Contraction pattern
1. Membrane status 5. Fundal height measurement 6. Contraction pattern Explanation: As part of the admission physical assessment, the nurse would assess fundal height, membrane status, and contractions. Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.
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? 1. Refrain from crossing legs when sitting down for long periods 2. Avoid sitting in one position for long periods of time 3. Applying heating pads on extremities 4. Refrain from wearing any kind of stockings
1. Refrain from crossing legs when sitting down for long periods Explanation: To help the client alleviate varicosities of the legs, the nurse should instruct the client to refrain from crossing her legs when sitting for long periods. The nurse should instruct the client to avoid standing, not sitting, in one position for long periods of time. The nurse should instruct the client to wear support stockings to promote better circulation, though the client should stay away from constrictive stockings and socks. Applying heating pads on the extremities is not reported to alleviate varicosities of the legs.
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? 1. Swimming in a pool is recommended exercise during pregnancy 2. More frequent tooth brushing is recommended to prevent caries related to ptyalism 4. Applying lanolin ointment to the breasts is recommended to prevent cracked nipples
1. Swimming in a pool is recommended exercise during pregnancy Explanation: Swimming in a pool is good exercise for a pregnant woman. However, swimming in a lake can be harmful because of the danger of infection, especially in the latter months. Douching can increase the risk of vaginal infections. Increased salivation or ptyalism, seen in some women during pregnancy, does not cause tooth decay and necessitate more frequent brushing. Lanolin ointments may damage the areola and nipple and have not been shown to be effective in preventing sore and cracked nipples.
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)? 1. Tay-Sachs disease 2. Down syndrome 3. cystic fibrosis 4. Turner syndrome
1. Tay-Sachs disease Tays-Sachs disease is a autosomal recessive disorder that occurs primarily in Ashkenazi Jews.
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? 1. one or two days before ovulation 2. any time after ovulation 3. a week after ovulation 4. any time during the week before ovulation
1. one or two days before ovulation To increase the chances of conceiving, the best time for intercourse is 1 or 2 days before ovulation. This ensures that the sperm meets the ovum at the right time. The average life of a sperm cell is 2 to 3 days, and the sperm cells will not be able to survive until ovulation if intercourse occurs a week before ovulation. The chances of conception are minimal for intercourse after ovulation.
Patterned breathing techniques used in labor provide which benefits? Select all that apply. 1. pain relief without special tools 2. conscious relaxation 3. distraction 4. spirituality
1. pain relief without special tools 2. conscious relaxation 3. distraction Patterned breathing can be very effective when the woman has practiced before labor and has an attentive coach. It can provide distraction, conscious relaxation, and pain relief without any special tools. The basic breathing patterns can be taught by the nurse and are easy to learn and simple to perform.
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. 1. straddling with forward-leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair 4. closed knee-chest position 5. supine with legs raised at a 90-degree angle
1. straddling with forward leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair Positioning during the first stage of labor includes walking with support from the partner; side-lying with pillows between the knees; leaning forward by straddling a chair, table, or bed; kneeling over a birthing ball; lunging by rocking weight back and forth with a foot up on a chair or birthing ball; or an open knee-chest position.
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? 1. the interval between the beginning and the end of one contraction 2. the interval between the acmes of two consecutive contractions 3. the end of one contraction to the beginning of the next 4. number of contractions that occur in 5 minutes
1. the interval between the beginning and the end of one contraction To determine the beginning of a contraction without a monitor, rest a hand on a woman's abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. This is the duration. Contractions are not timed by measuring the number of contractions in 5 minutes, the end of one contraction to the beginning of the next, or by using the interval between the acmes of two consecutive contractions.
A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching? 1."I will avoid having intercourse following the rupture of the membranes." 2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." 3. "I will experience a heightened need for touch throughout my pregnancy." 4. "If I experience bleeding, I will abstain from vaginal intercourse."
2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." Explanation: Sexual needs may be met through sexual intercourse with a partner as long as the pregnancy is healthy and there are no other risk factors, such as bleeding or rupture of membranes. Pregnancy is a time of a heightened need for touch, which may be met partially by sexual expression, but which can also be met through nonsexual touch, such as massage, caressing, or holding.
A nurse is explaining the fetus's position to a female client whose baby is in the frank breech position. Which statement by the client would indicate that the teaching was understood? 1."My baby's hips are extended, and the knees are flexed." 2. "My baby's hips are flexed, and the knees are extended." 3. "My baby's hips and knees are extended." 4. "My baby's hips and the knees are flexed."
2. "My baby's hips are flexed, and the knees are extended." The frank breech position of the fetus indicates that the sacrum is the presenting part. The hips are flexed, and the knees are extended. Complete breech is when both the hips and knees are flexed and the sacrum is presenting. Kneeling breech is when the hips are extended, and the knees are flexed. Footling breech is when both the hips and knees are extended so that the fetus presents feet first.
A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at: 1. 28 weeks' gestation 2. 36 weeks' gestation 3. 32 weeks' gestation 4. 16 weeks gestation
2. 36 weeks' gestation Explanation: Pregnant women between 36 and 37 weeks' gestation should be universally screened for GBS infection during a prenatal visit and, if positive, receive appropriate intrapartum antibiotic prophylaxis.
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? 1. Before reporting to the RN, determine the short term variability (STV). 2. Before reporting to the RN, determine the uterine contraction pattern. 3. Immediately report to the RN that the FHR shows no variability. 4. Immediately report to the RN that the FHR shows tachycardia.
2. Before reporting to the RN, determine the uterine contraction pattern. The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting.
Which body system is most affected throughout the embryonic and fetal period by teratogens? 1. musculoskeletal system 2. central nervous system 3. genitourinary system 4. gastrointestinal system
2. Central nervous system Whether the teratogen is ingested, injected, occurs through an infectious agent, or is environmental, the CNS and brain are the body systems most seriously affected during this period.
Which would be a normal finding by the nurse during a physical exam of a woman in her third trimester? 1. Kyphosis 2. Dyspnea 3. Increased hematocrit 4. Ptyalism
2. Dyspnea Explanation: In the third trimester, a women experiences dyspnea from the uterus pushing up into the diaphragm. A pregnant woman will experience lordosis, not kyphosis. Ptyalism is excessive saliva production and is often seen in the first trimester of pregnancy. The hematocrit of a pregnant woman will decrease in the third trimester, not increase.
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? 1. Assist the client into a hands-and-knees position. 2. Help the client regain control of her breathing technique. 3. Notify the RN that client's blood pressure has increased. 4. Notify the RN about the lack of FHR variability.
2. Help the client regain control of her breathing technique. The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is no improvement, notify the RN. Putting the client in the hands-and-knees position should be avoided until later in labor.
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? 1. Worrisome; it may be associated with metabolic acidosis. 2. Reassuring; it is associated with normal acid-base balance. 3. Damaging; it is frequently associated with fetal neurological damage. 4. Critical; it represents metabolic acidosis.
2. Reassuring; it is associated with normal acid-base balance. The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus.
The nurse is preparing materials to instruct a pregnant client about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the client? 1. General anesthesia 2. Regional anesthesia 3. Pressure anesthesia 4. Pudendal nerve blok
2. Regional anesthesia Regional anesthesia is the injection of a local anesthetic to block specific nerve pathways. This achieves pain relief by blocking sodium and potassium transport in the nerve membrane so the nerve is unable to conduct sensations. General anesthesia is rarely used and is not referred to as being general anesthesia. Pressure anesthesia results from the fetal head pressing against the stretched perineum. A pudendal nerve block is the injection of a local anesthetic through the vagina to anesthetize the pudendal nerve.
The nursing instructor is illustrating the circulatory flow between the mother and fetus. The instructor determines the session is successful when the class correctly chooses which structure with which route? 1. The two umbilical veins carry waste products from the fetus to the placenta. 2. The one umbilical vein carries oxygen-rich blood to the fetus from the placenta. 3. The two umbilical arteries carry waste products from the placenta to the fetus. 4. The one umbilical artery carries oxygen-rich blood to the fetus from the placenta.
2. The one umbilical vein carries oxygen-rich blood to the fetus from the placenta. Explanation: There are two umbilical arteries and one umbilical vein. The arteries carry waste from the fetus to the placenta; the vein carries oxygenated blood to the fetus from the placenta.
The nurse is assessing a pregnant woman on a routine prenatal visit. Which breast assessment finding will the nurse document as a normal and expected finding? 1. Disappearance of superficial veins 2. Tingling sensations and tenderness 3. Expression of colostrum in the first trimester 4. Hypopigmentation of the areola and nipples
2. Tingling sensations and tenderness Explanation: Normal changes in the breasts associated with pregnancy include tingling sensations and tenderness, enlargement of the breast and nipples, hyperpigmentation of the areola and nipples, enlargement of Montgomery glands (tubercles), prominence of superficial veins, development of striae (stretch marks), and expression of colostrum in the second and third trimesters.
A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best? 1. Maintain the client in the supine position. 2. Use distraction therapy. 3. Wrap the intravenous line with a cling wrap. 4. Instruct the client to lie still so not to dislodge the catheter.
2. Use distraction therapy. Many women in labor may receive intravenous fluid to maintain hydration. Distraction therapy helps the client to focus her attention on the birthing process. The woman can be out of bed with this in place. She should lie on her side as should all women in labor. Pediatric clients are upset by the site of the intravenous infusion site so the site is wrapped with a cling wrap or gauze.
A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? 1. Routine intravenous fluid should be implemented. 2. Women should be able to move about freely throughout labor. 3. A woman should be allowed to assume a supine position. 4. The support person's access to the client should be limited to prevent the client from becoming overwhelmed.
2. Women should be able to move about freely throughout labor. Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? 1. increased agitation 2. decreased alertness 3. low Apgar 4. increased crying
2. decreased alertness Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: 1. "I will need to lie on my right side to reduce vena cava compression." 2. "I can continue sitting up after the spinal is given." 3. "I may end up with a severe headache from the spinal anesthesia." 4. "The anesthesia will numb both of my legs to a level above my breasts."
3. "I may end up with a severe headache from the spinal anesthesia." Explanation: Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache.
A nurse is providing information regarding ovulation to a couple who want to have a baby. Which fact should the nurse tell the clients? 1. Ovulation takes place 10 days before menstruation. 2. When ovulation occurs, there is a rise in estrogen. 3. At ovulation, a mature follicle ruptures, releasing an ovum. 4. The lifespan of the ovum is only about 48 hours.
3. At ovulation, a mature follicle ruptures, releasing an ovum. At ovulation, a mature follicle ruptures, releasing a mature oocyte (ovum). Ovulation always takes place 14 days, not 10 days, before menstruation. The lifespan of the ovum is only about 24 hours, not 48 hours; unless it meets a sperm on its journey within that time, it will die. When ovulation occurs, there is a drop, not a rise, in estrogen levels.
A pregnant client in the second trimester is diagnosed with hyperemesis gravidarum with a 10% weight loss. The nurse is gathering data to form the foundation of a nutritional nursing care plan. Which way is best to obtain a nutritional assessment? 1. Outline the meals eaten over the past 7 days 2. Have the client complete an intake and output sheet 3. Complete a 24-hour food and fluid nutritional recall 4. Document food intake over the past 3 days
3. Complete a 24-hour food and fluid nutritional recall Explanation: Hyperemesis gravidarum causes dangerous health effects such as weight loss, dehydration, electrolyte imbalance, ketonuria, and ketonemia. It is important to complete a nutritional assessment, including everything that was ingested over the past 24 hours. The assessment includes both foods and fluids ingested. It is important to understand what was eaten in addition to what is recorded on the intake and output chart. It is most accurate to have the client recall the intake from the past 24 hours. It is unlikely that the client would recall all food and fluids ingested over the past 3 or 7 days.
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate? 1. Ask another nurse to assess the heart 2. Inquire if the patient has chest pain 3. Document this and continue to monitor the murmur at future visits 4. Refer her for cardiac catheterization
3. Document this and continue to monitor the murmur at future visits Explanation: Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal
A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? 1. Has weaker bones than normal 2. Is "male" shaped 3. Is narrow transversely 4. Is ideal for birth
3. Is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis.
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? 1. Distention of the vagina and perineum 2. Pressure on the lower back, buttocks, and thighs 3. Pain from the dilation or stretching of the cervix 4. Hypoxia of the contracting uterine muscles
3. Pain from the dilation or stretching of the cervix Explanation: In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.
Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first? 1. Ask the client to take deep breaths. 2. Administer an angiotensin-converting enzyme (ACE) inhibitor. 3. Raise the client's legs. 4. Place the client supine.
3. Raise the client's legs To help prevent supine hypotension syndrome, the nurse will place the pregnant client on the left side after an epidural block. If hypotension should occur, the client's legs should be raised in addition to providing oxygen, intravenous fluids, and medication such as an antihypotensive agent like ephedrine. The supine position encourages hypotension syndrome. Deep breathing would not nhelp with hypotension syndrome. An ACE inhibitor is an anti-hypertensive agent that would cause the client's blood pressure to decrease.
The nurse is caring for a client who had consistent exposure to lead while pregnant. When the neonate is born, which focused assessment is essential? 1. Muscle tone 2. Hearing 3. Reflexes 4. Swallowing ability
3. Reflexes Explanation: A factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead and mercury attack and disable nervous tissue. Assessment of reflexes and cognitive alertness is a priority. A hearing assessment is completed on most neonates in the nursery before discharge. Screening does not indicate lead poisoning. Muscle tone and the ability to swallow are not related to lead poisoning.
A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next? 1. Have the primary healthcare provider see the client 2. Ask the client if there is a family history of arthritis 3. Tell the client these are normal findings during pregnancy 4. Document these findings in the clients chart
3. Tell the client these are normal findings during pregnancy Explanation: The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should document this in the chart, but it is not priority over educating the client.
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? 1. imagery 2. oral pain medication 3. effleurage 4. lying still
3. effleurage Effleurage or massage would be an appropriate technique to use at this point. It is used as a distraction and relaxation technique. It increases the production of endorphins which reduce the transmission of signals between nerve cells and thus lowers the perception of pain. Imagery is another technique but may not be as effective for relieving the pain if it is intense. A change of position may help with the pain as the woman finds a position of comfort; lying still may not be effective. The use of oral pain medication presents a danger to the fetus depending on what is used, as it can pass through the placenta and adversely affect the heart and lungs of the fetus.
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? 1. follicle-stimulating hormone 2. androgens 3. estrogen 4. progesterone
3. estrogen Estrogens are responsible for developing and maintaining the female reproductive organs. Progesterone is the most important hormone for conditioning the endometrium in preparation for implantation of the fertilized ovum. Androgens, secreted by the ovaries in small amounts, are involved in the early development of the follicle and affect the female libido. Follicle-stimulating hormone is responsible for stimulating the ovaries to secrete estrogen.
The nurse is preparing an injection of an opioid to relieve a pregnant woman's pain. As the nurse is about to give it, the client asks for a bedpan because she has to move her bowels. The nurse's best action would be to: 1. give the injection, then offer the bedpan; abdominal comfort will help her move her bowels. 2. give the injection first, then offer the bedpan to complete a clean procedure before a contaminated one. 3. hold the injection until you evaluate her labor progress. 4. give the bedpan before you give the injection because the opioid is constipating.
3. hold the injection until you evaluate her labor progress. A feeling of having to move bowels or push with contractions could mean the woman is entering the second stage of labor. Abdominal discomfort does not affect a pregnant woman's urge to move her bowels. The nurse should hold off on the injection as it may be too late to be effective. The constipating effects of the opioid are not immediate.
Which is the most important factor on how much admission data is obtained when a client reports to the hospital in labor? 1. participation in childbirth class 2. amount of prenatal care 3. imminence of birth 4. support person with client
3. imminence of birth It is best for the nurse to obtain a full admission health history, a complete maternal physical assessment, the status of labor process, and cultural preferences. However, if the client's labor has progressed, there may be little information documented before the client is sent to the delivery room. Much of the admission information is personal data and pregnancy history that the client would be able to report. The preparation using prenatal care/classes and the presence of a support person does not influence admission data.
A nursing instructor identifies a need for further instruction in regards to the three stages of fetal development when a nursing student makes which statement? 1. "The embryonic stage begins approximately 2 weeks after fertilization." 2. "The fetal stage begins at 9 weeks after fertilization" 3. "The fetal stage ends at birth" 4. "The pre-embryonic stage begins approximately 2 weeks after fertilization"
4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" Explanation: The three stages of human development are the pre-embryonic stage, which begins at fertilization and lasts through the end of the second week after fertilization; the embryonic stage, which begins approximately 2 weeks after fertilization and ends at the conclusion of the 8th week after fertilization; and the fetal stage, which begins approximately 9 weeks after fertilization and ends at birth.
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? 1. Increase intake of meat 2. Reduce iron supplements 2. Take mineral oil 4. Increase fluid intake
4. Increase fluid intake Explanation: Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in fiber, which would include grains, vegetables, and fruits (instead of meat).
A maternal serum alpha-fetoprotein (MSAFP) test reveals a human chorionic gonadotropin (hCG) level of 2.5 MoM (multiple of median). Which teaching does the nurse prepare when the client and support person attend the next prenatal visit? 1. Information on delivering and caring for a multifetal pregnancy 2. Information on caring for a child with Tay-Sachs disease 3. Information on bleeding tendencies and hemophilia A 4. Information on further testing due to the risk for down syndrome
4. Information on further testing due to the risk for down syndrome Explanation: The nurse should inform the client that since the human chorionic gonadotropin (hCG) level is significantly elevated above 2 MoM, there is a significant risk for Down syndrome. Further information on what that means and further testing should be discussed at the next appointment. Also, misinformation should be clarified about having a child with Down syndrome. The MSAFP test does provide information about the risk for Tay-Sachs disease or hemophilia A. While hCG base levels may be slightly higher, the increases in levels (doubling pattern) remain the same as singleton pregnancies
The nurse is caring for a client in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this client's discomfort? 1. Place in a prone position 2. Place in the Trendelenburg position 3. Apply ice packs to the lower back 4. Massage the lower back
4. Massage the lower back Because the fetal head rotates against the sacrum in the occiput posterior position, the client may experience pressure and pain in the lower back because of sacral nerve compression. Applying counter pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain. The client does not need to be placed in the prone or Trendelenburg positions. Ice packs are not indicated to reduce this pain.
The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse anticipate being used to evaluate the fetus for potential neural tube defects? 1. Triple-marker screen 2. Amniocentesis 3. Doppler flow study 4. Maternal serum alpha-fetoprotein analysis
4. Maternal serum alpha-fetoprotein analysis Explanation: Alpha-fetoprotein is a substance produced by the fetus. AFP enters the maternal circulation by crossing the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus. The optimal time for AFP screening is 16 to 18 weeks. The triple marker screens for AFP, hCG, and unconjugated estriol. This screens for neural defects and Down syndrome. The Doppler flow study evaluates the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for chromosomal defects.
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. 1. Insulin 2. Testosterone 3. Thyroxine 4. Progesterone 5. Prostaglandins 6. Oxytocin
4. Progesterone 5. Prostaglandins 6. Oxytocin Explanation: There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
The nurse provides instructions to a client with hyperemesis gravidarum. Which outcome indicates that teaching has been effective? 1. The client is able to ingest clear liquids between episodes of vomiting. 2. The client has vomiting episodes only in the morning. 3. The client is able to tolerate soft foods after episodes of vomiting. 4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods.
4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. Explanation: The pregnant client with hyperemesis gravidarum may be hospitalized and treated with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started, and the woman discharged home. If able to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed to ensure she receives adequate nutrition. Vomiting episodes in the morning or tolerating clear liquids or soft foods between vomiting episodes indicates that teaching has not been effective.
Which of the following is not a physiologic basis for painful contractions during labor? 1. The descent of the fetus increases perineal pressure and stretching. 2. The presenting part of the fetus puts additional pressure on adjacent organs. 3. The cervix is stretched. 4. Uterine and cervical blood vessels dilate, increasing blood flow and causing hypoxia in the muscle fibers.
4. Uterine and cervical blood vessels dilate, increasing blood flow and causing hypoxia in the muscle fibers. Uterine and cervical blood vessels constrict, reducing blood flow and causing anoxia in the muscle fibers.
ROA was documented in the babys chart. Which position was the baby born in? 1. Rear facing with the occiput facing the posterior quadrant of the pelvis 2. With the brow facing the right anterior quadrant of the pelvis 3. With the right side presenting, and the occiput facing the anterior quadrant 4. With the occiput facing the right anterior quadrant of the pelvis
4. With the occiput facing the right anterior quadrant of the pelvis A fetus in the vertex presentation has the occiput as the reference point. If the occiput is facing the anterior quadrant of the pelvis, the nurse is correct to record the position as ROA. Proper notation does not include a rear or right facing position. The vertex presentation is associated with the fetal occiput, not brow.
A female client is concerned about the rate of fertility because the client is older than age 35 years. The client states, "Have I given up the chance to be a parent?" Which response from the nurse is accurate?
"A woman's fertility peaks in the 20s, declines gradually until age 35, and then rapidly declines until it ends."
The labor and delivery charge nurse is making assignments for the day. Which client should the charge nurse assign to a nurse with 6 months experience in labor and delivery? 1. A gravida 5 para 2 mother in active labor 2. A gravida 3 para 0 mother at 36 weeks' gestation 3. A gravida 1 para 0 mother with mild preeclampsia 4. A gravida 2 para 1 mother for TOLAC
1. A gravida 5 para 2 mother in active labor The gravida 5 para 2 mother is in active labor, is in no apparent distress, and is expected to deliver without complications. The other 3 clients all have documented medical problems and may require more experience and critical thinking than the new nurse with only 6 months experience.
A nursing student is explaining to a newly pregnant woman what happens during each stage of fetal development. At which stage does the nurse inform the woman that the lungs are fully shaped? 1. End of 16 weeks 2. End of 8 weeks 3. End of 4 weeks 4. End of 12 weeks
1. End of 16 weeks Explanation: At the end of 16 weeks, the lungs are fully shaped, fetus swallows amniotic fluid, skeletal structure is identifiable, downy lanugo hair is present on the body, and sex can be determined using ultrasound.
During which phase of labor would the nurse anticipate providing the most emotional support for the mother? 1. Final phase of labor 2. Latent phase of labor 3. Active phase of labor 4. Transition phase of labor
4. Transition phase of labor The transition phase of labor is the most difficult. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation (dilatation). The contractions at this point are strong and lasting 60 to 90 seconds. It is important for the nurse to help the woman through this stage and encourage her to rest between contractions.
The nurse cares for multiple clients planning to have children. Which client will the nurse identify as priority for needing a referral for prenatal genetic testing?
A male client with a family history of sickle cell disease. The nurse would refer the male client with a family history of a sickle cell disease, a genetic disorder, for prenatal genetic testing. Women older than 35 years of age and men older than 45 years of age should be referred. However, age is not priority over a known family history. Women with diabetes need not necessarily be referred for genetic testing.
