OB Exam 3 Questions

The nurse thoroughly dries the infant immediately after birth primarily to: a.reduce heat loss from evaporation. b.stimulate crying and lung expansion. c.increase blood supply to the hands and feet. d.remove maternal blood from the skin surface.

A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

Which of the following would indicate an abnormal finding during the postpartum period? a.Lochia flow changing from alba to rubra b.Unable to palpate uterine fundus at 6-week postpartum checkup c.Presence of afterbirth pains d.Lochia flow heavier in the early morning 2 days following vaginal birth

A Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding. The uterine fundus should no longer be palpable at 2 weeks postbirth. Afterbirth pains during the postpartum period are a normal finding based on involution of the uterus. Lochia flow may be heavier on arising because of the effects of gravity and pooling of blood while recumbent

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a.18-gauge b.20-gauge c.22-gauge d.24-gauge

A The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

During labor a vaginal examination should be performed only when necessary because of the risk of: a.infection. b.fetal injury. c.discomfort. d.Perineal trauma.

A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

Which vaccinations are indicated for the postpartum client if she does not have immunity? (Select all that apply.) a.Pertussis b.Rubella c.Diphtheria, tetanus (Tdap) d.RhoGAM

A,B,C If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results.

The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the babys head? a.Expulsion b.Restitution c.Internal rotation d.External rotation

B After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head

A postpartum client overhears the nurse tell the health care provider that she has a positive Homans sign and asks what it means. Which is the nurses best response? a.You have pitting edema in your ankles. b.You have deep tendon reflexes rated 2+. c.You have calf pain when the nurse flexes your foot. d.You have a fleshy odor to your vaginal drainage.

C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul odor, is within normal limits.

When assessing the A of the acronym REEDA, the nurse should assess the: a.skin color. b.degree of edema. c.edges of the episiotomy. d.episiotomy for discharge.

C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage

If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included? a.No specific instructions b.Drinking plenty of fluids to prevent fever c.Recommendation to stop breastfeeding for 24 hours after the injection d.Explanation of the risks of becoming pregnant within 28 days following injection

D Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.

Which documentation in the clients chart on the 14th postpartum day indicates a normal involution process? a.Breasts firm and tender b.Episiotomy slightly red and puffy c.Moderate bright red lochial flow d.Fundus below the symphysis and not palpable

D The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa.

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a.Formal b.Informal c.Personal d.Anticipatory

A A major task of the formal stage of role attainment is getting acquainted with the infant. The informal stage begins once the parents have learned appropriate responses to their infants cues. The personal stage is attained when parents feel a sense of harmony in their role. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes.

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a.Letting-go b.Taking-in c.Taking-on d.Taking-hold

A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase, the mother assumes responsibility for her own care and shifts her attention to the infant.

Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth? a.Bloody mucous discharge increases. b.The vulva bulges and encircles the fetal head. c.The membranes rupture during a contraction. d.The fetal head is felt at 0 station during the vaginal examination.

B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

An example of binding in during the postpartum period is a: a.new mother telling her friends all about her labor and birth experience. b.father looking at his newborn and stating that he looks like I did when I was a baby. c.mother reporting increasing anxiety during the postpartum period because she feels like she is all alone. d.mother wanting some time alone so that she can catch up on needed sleep.

B A new mother telling her friends all about her labor and birth experience is an example of binding in or claiming. A new mother telling her friends all about her labor and birth experience is an example of the taking-in phase of maternal adaptation. A mother who reports increasing anxiety during the postpartum period because she feels like she is all alone may be problematic and indicates that the client is experiencing significant stressors during the postpartum period. A mother wanting some time alone so that she can catch up on needed sleep is a normal reaction to the demands of the newborn and reflects that the client may need additional support during this time.

A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are: a.contraction pattern, amount of discomfort, and pregnancy history. b.fetal heart rate, maternal vital signs, and the womans nearness to birth. c.last food intake, when labor began, and cultural practices the couple desires. d.identification of ruptured membranes, the womans gravida and para, and her support person.

B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the womans gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

At 5 minutes after birth, the nurse assesses that the neonates heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a.7 b.8 c.9 d.10

B The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

A nursing priority during admission of a laboring client who has not had prenatal care is: a.obtaining admission labs. b.identifying labor risk factors. c.discussing her birth plan choices. d.Explaining importance of prenatal care.

B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patients history has been completed.

When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.) a.Check the DTR each shift. b.Monitor and record vital signs frequently during the course of labor. c.Document the FHR pattern, noting baseline and response to contraction patterns. d.Indicate on the EFM tracing when maternal position changes are done. e.Provide food, as tolerated, during the course of labor.

B,C,D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

The nurse decides to perform a prescribed PRN intermittent sterile catheterization on a postpartum client if which occurs? (Select all that apply.) a.The client has not voided but the bladder cannot be palpated. b.The fundus is displaced from the midline and the client has been unable to void. c.The client has been medicated for pain but she has not voided; the fundus is midline. d.The amount voided is less than 150 mL and the fundus is displaced from the midline.

B,D The nurse makes the decision to perform an intermittent sterile catheterization if the client is unable to void, the amount is less than 150 mL, and the fundus is displaced. A nonpalpable bladder and firm fundus at or below the umbilicus and in the midline confirm that the bladder is empty and rule out urinary retention with overflow.

While the nurse is demonstrating a baby bath, the client states, The other nurse told me to do it a different way. Which response should the nurse make? a.Tell her to do the procedure whichever way works best for her. b.Confront the other nurse about her knowledge of the procedure. c.Reassure her that procedures are based on standard principles and may vary. d.Tell her that the other nurse does not have much experience in caring for newborns.

C Procedures may vary as long as basic principles are included. There is no evidence that the other nurse gave incorrect information. Telling her whichever way works best or the other nurse does not have much experience do not answer her concerns.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a.Pain level 5 on scale of 0 to 10 b.Saturated pad over a 2-hour period c.Urinary output of 500 mL in one voiding d.Uterine fundus 2 cm above the umbilicus

D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client.

The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment? a.Check for edema. b.Checkfor range of motion. c.Check for adequate reflexes. d.Check for deep vein thrombosis.

D Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis. Edema is checked by palpating and pressing on the top of the foot, range of motion is not a postpartum assessment, and reflexes are checked at the patellar area

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a.Fever and increased blood pressure b.Postpartum hemorrhage and eclampsia c.Urinary tract infection and uterine rupture d.Postpartum hemorrhage and urinary tract infection

D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.

A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after birth because of: a.increased estrogen. b.increased progesterone. c.decreased human placental lactogen. d.decreased melanocyte-stimulating hormone.

D Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation

Which should the nurse recognize as being associated with fetal compromise? a.Active fetal movements b.Fetal heart rate in the 140s c.Contractions lasting 90 seconds d.Meconium-stained amniotic fluid

D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history? a.Client has not been pregnant. b.Client has had a C section as a method of birth. c.Client has been treated for an STD with resultant scarring of the cervix. d.Client has a history of pregnancy.

D With pregnancy, the cervix becomes slitlike in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth. Treatment of STD is not associated with cervical changes.

A husband calls the nurses station stating that his wife, who delivered last week, is happy one minute and crying the next. He says, She was never like this before the baby was born. Which should be the nurses initial response? a.Reassure him that this behavior is normal. b.Advise him to get immediate psychological help for her. c.Tell him to ignore the mood swings because they will go away. d.Instruct him in the signs, symptoms, and duration of postpartum blues.

A Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Postpartum blues are a normal process that is short-lived; no medical intervention is needed. Telling him to ignore the moods blocks communication and may belittle the husbands concerns. Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching.

The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the clients record? a.Fetal heart rate b.Pain level c.Test results ensuring that the fluid is not urine d.The clients understanding of the event

A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The clients understanding of the event would only need to be documented if it presents a problem.

In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth? a.Quantity of lochia rubra b.Pain management techniques c.Frequency of vital signs and fundal checks d.Assessment of infection risk from loss of skin integrity

B A cesarean section is major surgery. Pain relief is provided in various ways, including patient-controlled analgesia and oral and intramuscular analgesics. Postvaginal birth pain is managed with oral analgesic combinations that include acetaminophen; the quantity of lochia, frequency of vital signs, and fundal checks and assessment of infection risk are the same for both types of birth.

Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor? a.Length of second-stage labor is 2 hours. b.Client has received an epidural for pain control during the labor process. c.Client is using breathing techniques during contractions to maximize pain relief. d.Client is receiving parenteral fluids during the course of labor to maintain hydration.

B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

The term reciprocal attachment behavior refers to which of the following? a.Behavior during the sensitive period when the infant is in the quiet alert stage b.Positive feedback an infant exhibits toward parents during the attachment process c.Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d.Behavior by the infant during the sensitive period to elicit feelings of falling in love from the parents

B In this definition, reciprocal refers to the feedback from the infant during the attachment process. The quiet alert state is a good time for bonding but does not define reciprocal attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional.

Which action should the nurse do to provide support and encouragement to the new postpartum client? a.Recount how she solved her own problems. b.Correct the new mother at every opportunity. c.Praise the mothers early attempts at infant care. d.Explain to the new mother that everything will be fine.

C Positive reinforcement of the mothers attempt to provide care to the newborn will promote a healthy self-concept. The mother needs to learn how to solve problems on her own. Each person may use different techniques that work for that person. Correcting her actions would be discouraging to a new mother. She needs encouragement. Saying everything will be fine is blocking communication and further teaching.

The nurse examines a primiparas cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurses priority action? a.Palpate her bladder for fullness. b.Assess the frequency and duration of her contractions. c.Determine who will stay with the patient for the birth. d.Encourage the patient to exhale in short breaths with contractions.

D Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patients urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

Rho(D) immune globulin will be ordered postpartum if which situation occurs? a.Mother Rh-negative, baby Rh-positive b.Mother Rh-negative, baby Rh-negative c.Mother Rh-positive, baby Rh-positive d.Mother Rh-positive, baby Rh-negative

A An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mothers blood, not the infants.

If the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? a.Document the finding. b.Tell the health care provider. c.Begin antibiotic therapy immediately. d.Have the laboratory draw blood for reanalysis.

A An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. Because this is a normal finding, there is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated

Which assessment finding could indicate hemorrhage in the postpartum patient? a.Elevated pulse rate b.Elevated blood pressure c.Firm fundus at the midline d.Saturation of two perineal pads in 4 hours

A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a.Helps the new parents identify resources b.Recommends employing babysitters frequently c.Tells the parents about the realities of parenthood d.Offers a home phone number and tells parents to call if they have a question

A Available resources within the community can assist the parents in role transition. Some parents may not be able to afford babysitters. Also, this removes them from the parenthood role. Each adult sees parenthood in a different light. They cannot be compared. Searching out resources for the parents is an important task. However, the nurse should not give her personal number to clients.

The nurse observes a client on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which appropriate action should the nurse take? a.Hand the baby to the woman. b.Explain taking-in to the woman. c.Offer to hand the baby to the woman. d.No action, because this situation is perfectly acceptable.

A During the taking-in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision. This is expected behavior during the taking-in phase. However, interventions can facilitate infant bonding.

The postpartum nurse is reviewing dietary practices for an Asian client. Which should the nurse expect to observe as a dietary practice for this culture? a.Food brought from home b.Preference for fresh fruits c.Preference for cold foods d.Request for ice water instead of hot water

A Food brought from home is a welcome sign of caring in many cultures. Some Asians believe that after childbirth the woman should eat only hot foods such as chicken, meat, and fish. Fresh fruit would be considered a cold food. Although ice water is commonly given to hospital clients, it is not acceptable to many Asians. For example, Southeast Asian women may refuse cold or ice water and prefer hot water or other warm beverages to keep warm

Which comfort measure should a nurse use to assist a laboring woman to relax? a.Recommend frequent position changes. b.Palpate her filling bladder every 15 minutes. c.Offer warm wet cloths to use on the clients face and neck. d.Keep the room lights lit so the client and her coach can see everything.

A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

Which is an essential part of nursing care for a laboring client? a.Helping the woman manage the pain b.Eliminating the pain associated with labor c.Feeling comfortable with the predictable nature of intrapartal care d.Sharing personal experiences regarding labor and birth to decrease her anxiety

A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

The postpartum client who continually repeats the story of her labor, birth, and recovery experiences is doing which? a.Making the birth experience real b.Accepting her response to labor and birth c.Providing others with her knowledge of events d.Taking hold of the events leading to her labor and birth

A Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. She is in the taking-in phase, trying to make the birth experience seem real. This is to satisfy her needs, not the needs of others. She is trying to make the event real and is trying to separate the infant from herself.

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a.No swelling or edema to the perineal area b.Patient complains that the sitz bath is too cold c.Patient reports she took two sitz baths in 12 hours d.Edges of the perineal laceration are well approximated

A Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma.

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a.Inform the mother that the rate is normal. b.Reassess the fetal heart rate in 5 minutes because the rate is too high. c.Report the fetal heart rate to the physician or nurse-midwife immediately. d.Tell the mother that she is going to have a boy because the heart rate is fast.

A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic? a.Gravida 5, para 5 b.Primipara who delivered a 7-lb boy c.Client who is bottle feeding her first child d.Client who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse.

A new father states, I know nothing about babies, but he seems to be interested in learning. The nurse should take which action? a.Include him in teaching sessions. b.Tell him when he does something wrong. c.Show no concern because he will learn on his own. d.Continue to observe his interaction with the newborn.

A The nurse must be sensitive to the fathers needs and include him whenever possible. He should be encouraged by pointing out the correct procedures he does. By criticizing, he will be discouraged. Showing no concern is not a nursing role. Nurses need to be sensitive to clients needs. It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father.

If a womans fundus is soft 30 minutes after birth, the nurses first response should be to: a.massage the fundus. b.take the blood pressure. c.notify the physician or nurse-midwife. d.place the woman in Trendelenburg position.

A The nurses first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which? a.Distended bladder b.Normal involution c.Been lying on her right side too long d.Stretched ligaments that are unable to support the uterus

A The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus.

When using the second Leopolds maneuver in fetal assessment, the nurse would palpate (the): a.both sides of the maternal abdomen. b.lower abdomen above the symphysis pubis. c.both upper quadrants of the maternal abdomen . d.lower abdomen for flexion of the presenting part.

A The second Leopolds maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

Which client is most likely to have the least stress adjusting to her role as a mother? a.A 26-year-old woman who is returning to work in 10 weeks b.A 35-year-old anxious mother who has had no contact with babies or children c.A 16-year-old teenager who lives with her parents and has a strained relationship with her mother d.A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth

A The woman who has the least amount of stress in her life will adjust more quickly to her role as a mother. The anxious mother with no real experience with babies may have a difficult time adjusting to motherhood. The teenager has a significant amount of stress in her life, which could make adjusting to her role as a mother more difficult. The 25-year-old mother has the added stress of twins, which may make motherhood adjustment more difficult.

A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a.Less maternal fatigue b.Less birth canal injuries c.Decreased pushing time d.Faster descent of the fetus e.An increase in frequency of contractions

A,B,C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her bodys signals. A brief slowing of contractions often occurs at the beginning of the second stage.

Which interventions are required following an amniotomy procedure? (Select all that apply.) a.Notation related to amount of fluid expelled b.Color and consistency of fluid c.Fetal heart rate d.Maternal blood pressure e.Maternal heart rate

A,B,C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

Which are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) a.Provide comfort and ample time for rest. b.Keep the baby wrapped to avoid cold stress. c.Position the infant face to face with the mother. d.Point out the characteristics of the infant in a positive way. e.Limit the amount of modeling so the mother doesnt feel insecure.

A,C,D Provide comfort and ample time for rest, because the mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of the infant. Position the infant in an en face position and discuss the infants ability to see the parents face. Face to face and eye to eye contact is a first step in establishing mutual interaction between the infant and parent. Point out the characteristics of the infant in a positive way: She has such pretty little hands and beautiful eyes. The baby should be kept warm, but parents should be assisted to unwrap the baby (keeping or rewrapping the body part not being inspected) to inspect the toes, fingers, and body. The nurse should model behaviors by holding the infant close, making eye contact with the infant, and speaking in high-pitched, soothing tones.

Which strategies should the nurse suggest to a postpartum client to promote stress reduction during the first weeks at home? (Select all that apply.) a.Limiting coffee, tea, cola, and any caffeinated beverages b.Maintaining a rigid schedule c.Sleeping when the infant sleeps d.Inviting visitors and friends to stop by frequently e.Using learned breathing techniques from childbirth classes for relaxation

A,C,E To promote stress reduction during the first weeks at home, the nurse can suggest that parents limit coffee, tea, colas, and chocolate, because they contain caffeine and will interfere with rest. Recommend that the mother sleep when the infant sleeps and conserve her energy for care of the baby. Suggest breathing exercises and progressive relaxation to reduce stress and increase her energy level, especially when a nap is not possible. The schedule should be flexible; a rigid schedule or meticulous environment increases tension within the family. The parents should let friends and relatives know sleep and nap times and request that they limit visits or telephone before visiting.

The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a.I will gently pat the perineum dry rather than wipe. b.I will only use the perineal bottle after bowel movements. c.I will use cold water in the perineal bottle as I cleanse. d.I will use the perineal bottle without touching the perineum.

A,D The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements.

The nurse is teaching a nonbreastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.) a.Avoid massaging the breasts. b.Allow warm shower water to run over the breasts. c.If the breasts become engorged, pumping is recommended . d.Ice packs can be applied to the breasts to relieve discomfort. e.Wear a sports bra 24 hours a day until the breasts become soft.

A,D,E The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production

A 25-year-old gravida 1, para 1, who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Which should be your initial action? a.Assess her for pain. b.Allow her time to express her feelings. c.Point out how lucky she is to have a healthy baby. d.Explain that she is experiencing postpartum blues.

B Although many women experience transient postpartum blues, they need assistance in expressing their feelings. Assessing her for pain assumes that she is in pain. Pointing out how lucky she is to have a healthy baby is blocking communication. She needs the opportunity to express her feelings first. Later, client teaching can occur.

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a.Bloody b.Clear with bits of vernix caseosa c.Green and thick d.Yellow and cloudy with foul odor

B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a.Saturated peripad b.4- to 6-inch stain on the peripad c.1- to 4-inch stain on the peripad d.Less than a 1-inch stain on the peripad

B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: Scantless than a 1-inch stain on the peripad Light1- to 4-inch stain Moderate4- to 6-inch stain Heavysaturated peripad Excessivesaturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery

A gravida 1, para 0, 38 weeks gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, 1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time? a.Performing more frequent vaginal exams will not make the labor go any quicker. b.Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c.Tell the client that she will check every 30 minutes. d.Medicate the client as needed for anxiety so that the labor can progress.

B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address clients anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a.I may not have a bowel movement until the 2nd postpartum day. b.If I breastfeed and supplement with formula, I wont need any birth control. c.I know my normal pattern of bowel elimination wont return until about 8 to 10 days. d.If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband.

B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.

Which fundal assessment finding at 12 hours after birth requires further assessment? a.The fundus is palpable at the level of the umbilicus. b.The fundus is palpable two fingerbreadths above the umbilicus. c.The fundus is palpable one fingerbreadth below the umbilicus. d.The fundus is palpable two fingerbreadths below the umbilicus.

B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum, but is still appropriate

The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a.Place the catheter as quickly as possible. b.Place a small pillow under the patients left hip. c.Omit the use of a cleansing agent, such as Betadine. d.Set up the catheter tray before positioning the patient.

B To promote placental function, the nurse can place a small pillow or rolled blanket under the patients left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a.Place the infant covered with blankets in the radiant warmer. b.Dry the infant off with sterile towels. c.Place stockinette cap on infants head. d.Bathe the newborn within 30 minutes of birth. e.Remove wet linen as needed.

B,C,E Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infants head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period

The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.) a.Mild incisional pain b.Feeling of pelvic fullness c.Lochia changing from red to pink in color d.Frequency, urgency, or burning on urination e.Redness or edema of the abdominal incision

B,D,E The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa)

A client at 40 weeks gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: a.fetal movement. b.irregular contractions for 1 hour. c.a trickle of fluid from the vagina. d.thick pink or dark red vaginal mucus.

C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

Which is the best measure to prevent abdominal distention following a cesarean birth? a.Rectal suppositories b.Carbonated beverages c.Early and frequent ambulation d.Tightening and relaxing abdominal muscles

C Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs, but do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention.

The health care provider has asked the nurse to prepare for an amniotomy. What is the nurses priority action with this procedure? a.Perform Leopolds maneuvers. b.Determine the color of the amniotic fluid. c.Assess the fetal heart rate immediately after the procedure. d.Prepare the patient for a change in her pain level after the procedure.

C An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopolds maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor.

The nurse is developing a plan of care for the patients fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process? a.Encourage the patient to call the baby by his or her first name. b.Stimulate the grasp reflex by placing the patients finger in the infants palm. c.Ask the patient if she wants her baby placed on her chest immediately after birth. d.Assess for familial characteristics and remark on the resemblance to the patient or the father.

C Bonding refers to the rapid initial attraction felt by parents for their infant. It is unidirectional, from parent to child, and is enhanced when parents and infants are permitted to touch and interact during the first 30 to 60 minutes after birth. During this time, the infant is in a quiet, alert state and seems to gaze directly at the parents. Infants are often placed skin to skin on the mothers chest or abdomen for bonding time immediately after birth. Nurses frequently delay procedures such as measurements and medication administration that would interfere with this time, so that parents can focus on their newborn baby. Attachment follows a progressive or developmental course that changes over time. It is rarely instantaneous. Unlike bonding, attachment is reciprocalit occurs in both directions between parent and infant.

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a.Pulse rate of 50 b.Temperature of 38 C (100.4 F) c.Firm fundus, but excessive lochia d.Lightheaded when moving from a lying to standing position

C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38 C (100.4 F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand

Which of the following behaviors would be applicable to a nursing diagnosis of risk for impaired parenting? a.En face behavior is observed between father and infant. b.Mother relates that she feels exhilarated postbirth. c.Mother states that she feels excessive fatigue as a result of the childbirth experience. d.Father displays finger tipping behavior toward infant

C Fatigue can contribute to altered parenting because it may affect the level of interaction between parent and child. En face behavior acknowledges maternal-paternal attachment. A feeling of exhilaration is normal following a changing life cycle event such as childbirth. Finger tipping behavior conveys a sense of identification or claiming behavior

The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a.Decrease IV fluid rate. b.Document the finding. c.Encourage the use of an incentive spirometer. d.Ambulate the client around the nurses station.

C Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses station should not be done at this time

The nurse is preparing to perform Leopolds maneuvers. Why are Leopolds maneuvers used by practitioners? a.To determine the status of the membranes b.To determine cervical dilation and effacement c.To determine the best location to assess the fetal heart rate d.To determine whether the fetus is in the posterior position

C Leopolds maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a.Request a social service consult for psychosocial support. b.Observe for other signs that the mother may not be accepting of the infant. c.Document this evidence of normal early maternal-infant attachment behavior. d.Determine whether the mother is too fatigued to interact normally with her infant.

C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

The nurse is teaching new parents about behavior cues that indicate their infant has had enough stimulation. Which cues should the nurse include in the teaching session? a.The infant kicks his legs. b.The infant is quiet and alert. c.The infant splays his fingers. d.The infant looks at their faces.

C Nurses should help parents recognize signals that indicate when their infant has had enough interaction and wants to avoid further stimulation. These avoidance cues, such as looking away, splaying the fingers, arching the back, and fussiness, indicate that the infant needs a quiet time. Kicking legs, being quiet and alert, and looking at faces are not clues the infant is overstimulated.

A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a.Obtain a fetal heart rate. b.Determine the estimated due date. c.Auscultate anterior and posterior breath sounds. d.Ask the client when she last had something to eat.

C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and painlocation, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

The Centers for Disease Control and Prevention (CDC) recommends the use of which personal protective equipment with which the nurse is likely to come into contact? a.Any body fluids b.Any client at any time c.Blood and blood products d.Any client suspected of being HIV-positive

C Possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids. Only certain body fluids can cause contamination. It is not necessary to wear protective equipment continually with all clients. Protective equipment is important with a client if the nurse is at risk for contamination with blood or certain body fluids. The equipment does not have to be worn with casual contact.

A family is concerned about how their 2-year-old son is going to react to the new baby. What intervention would help facilitate sibling attachment? a.Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b.Make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c.Include the son in helping to take care of the baby and reinforce the label of big brother as a special role. d.Observe the sons reaction to the baby and let him decide when he wants to be introduced to his new sibling.

C Providing the older son with a special role designation and involving him in the care of the baby will facilitate sibling attachment. Spending individual time with the older child is recommended but will not facilitate sibling attachment. Although the older child should be supervised because of his age in terms of infant safety, this level of overprotection may inhibit sibling attachment. Observation of his behavior may be warranted, but the age of the child (2 years) does not warrant this type of control.

A postpartum client asks, Will these stretch marks go away? Which is the nurses best response? a.No, never. b.Yes, eventually. c.They will fade to silvery lines but wont disappear completely. d.They will continue to fade and should be gone by your 6-week checkup.

C Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. The Apgar score for this infant is: a.7. b.8. c.9. d.10.

C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue hands and feet. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding? a.Weigh the peripad. b.Replace the peripad. c.Contact the health care provider. d.Document the finding in the patients chart.

C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

A postpartum nurse is observing a client holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back. Which action should the nurse should take? a.Report the incident to the social services department. b.Advise the parents that the older son needs to be reprimanded. c.No action; this is a normal family adjusting to family change. d.Report to oncoming staff that the mother is probably not a good disciplinarian.

C The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate as parents. This is normal for an adjusting family.

The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time? a.To apply internal monitoring electrodes b.To assess for Goodells sign c.To determine cervical dilation and effacement d.To determine strength of contractions

C The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodells sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

A postpartum client who is a gravida 4, para 4, comes to the office for her 6-week postpartum checkup. Her presentation is untidy and unkempt. The client states that she is not sleeping well and relates that she feels overwhelmed at times. According to the client, family members responses have been nonsupportive. What recommendations would you advise to help the client at this time? a.Tell the client that this is a normal reaction to an increase in family size and that listening to music can help relieve anxiety. b.Tell the client to increase her exercise pattern because that will promote a sense of well-being. c.Make appropriate referrals for psychological intervention counseling because the client is exhibiting high-risk symptoms. d.Record the clients vital signs as part of the ongoing assessment and offer relaxation strategies as a method of support.

C This client is exhibiting symptoms that are consistent with postpartum depression, so she should be given priority intervention to maintain client safety.

Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a.Fluid volume deficit (FVD) related to fluid loss during labor and birth process b.Fatigue related to length of labor requiring increased energy expenditure c.Acute pain related to increased intensity of contractions d.Anxiety related to imminent birth process

D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

Which should the nurse do to provide support to a new client who must return to full-time employment 6 weeks after a vaginal birth? a.Discuss child care arrangements with her. b.Allow her to solve the problem on her own. c.Reassure her that shell get used to leaving her baby. d.Allow her to express her positive and negative feelings freely.

D Allowing the client to express feelings will provide positive support in her process of maternal adjustment. Discussing child care arrangements is an important step in anticipatory guidance but is not the best way to offer support. She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision. Reassuring her that she will get used to leaving the baby blocks communication and belittles the clients feelings.

The gynecologist performs an amniotomy. What will the nurses role include immediately following the procedure? a.Assessing for ballottement b.Conducting a pH and/or fern test c.Labeling of specimens for chromosomal analysis d.Recording the character and amount of amniotic fluid

D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

The nurse has given the newborn an Apgar score of 5. She should then: a.begin ventilation and compressions. b.do nothing except place the infant under a radiant warmer. c.observe the infant and recheck the score after 10 minutes. d.gently stimulate by rubbing the infants back while administering O2.

D An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborns transition to extrauterine life.

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a.Assess lochial flow rather than palpating the fundus. b.Palpate forcefully through the abdominal dressing. c.Place hands on both sides of the abdomen and press downward. d.Gently palpate, applying the same technique used for vaginal deliveries.

D Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.

To promote bonding and attachment immediately after birth, which action should the nurse take? a.Assist the mother in feeding her baby. b.Allow the mother quiet time with her infant. c.Teach the mother about the concepts of bonding and attachment. d.Assist the mother in assuming an en face position with her newborn.

D Assisting the mother in assuming an en face position with her newborn will support the bonding process. After birth is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process. The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time.

A new mother states, My mother-in-law will be here from out of town for a few weeks. Im afraid she will take over the care of the baby. Which response should the nurse make? a.Tell the client that everything will be okay. b.Tell the client how lucky she is to have someone to help her. c.Encourage the client to allow her mother-in-law to take care of the newborn. d.Encourage the client to tell her mother-in-law that she (the new mother) wants to care for her infant.

D Before the mother-in-law has the opportunity to take over, the mother needs to state her own desire to care for the infant. Telling the client everything will be okay or she is lucky does not address the clients concern and are dismissive. The new mother needs to believe that she can care for her baby and should express this to the mother-in-law so she will not feel resentful in the future.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a.Have the client drink carbonated beverages to promote urinary excretion. b.Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c.Limit fluid intake to prevent polyuria. d.Teach the client to do pelvic floor exercises to combat potential stress incontinence.

D Educating the client to use pelvic floor exercises will help strengthen pelvic muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the client is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period

Which maternal event is abnormal in the early postpartal period? a.Diuresis and diaphoresis b.Flatulence and constipation c.Extreme hunger and thirst d.Lochial color changes from rubra to alba

D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Which client at term should go to the hospital or birth center the soonest after labor begins? a.Gravida 2, para 1, who lives 10 minutes away b.Gravida 1, para 0, who lives 40 minutes away c.Gravida 2, para 1, whose first labor lasted 16 hours d.Gravida 3, para 2, whose longest previous labor was 4 hours

D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurses best response? a.When did these symptoms begin? b.Sounds like normal postpartum depression. c.Are you having trouble getting enough sleep? d.Are you able to get out of bed and provide care for your baby?

D Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and resolve in 2 weeks. The response Sounds like postpartum depression does not offer the patient any help or encouragement through this challenging time. Asking if she is getting enough sleep does not add to the assessments already identified in the stem. Enough information exists to determine that she has the signs and symptoms of postpartum blues. The nurse must differentiate between postpartum blues and depression.

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding? a.Inform the health care provider. b.Encourage the patient to urinate. c.Massage the uterus to expel clots. d.Document the finding in the patients chart.

D The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed.

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be: a.discharged home with a sedative. b.admitted for extended observation. c.admitted and prepared for a cesarean birth. d.discharged home to await the onset of true labor.

D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husbands hand away and shouts, Dont touch me! This behavior is most likely: a.abnormal labor. b.a sign that she needs analgesia. c.normal and related to hyperventilation. d.common during the transition phase of labor.

D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? a.Narcotics b.Spinal block c.Epidural anesthesia d.Breathing and relaxation techniques

D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn.

Which of the following is the priority intervention for the client in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? a.Administer O2 at 8 to 10 L/min. b.Decrease the IV rate to 100 mL/hr. c.Reposition the ultrasound transducer. d.Perform a vaginal exam to assess for cord prolapse.

A A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the clients blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation.

Which of the following factors would affect pain perception or tolerance for the laboring client? a.Right occiput posterior fetal position during labor b.Bishop score of 10 prior to the induction of labor c.Gynecoid pelvis d.Absence of Fergusons reflex

A A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Fergusons reflex occurs when a contraction is stimulated as a result of vaginal stimulation.

Which maternal factor may inhibit fetal descent? a.A full bladder b.Decreased peristalsis c.Rupture of membranes d.Reduction in internal uterine size

A A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

Which client is a candidate for internal monitoring with an intrauterine pressure catheter? a.Obese client whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds b.Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds c.Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds d.Gravida 2, para 1, in latent phase whose contractions are irregular and mild

A A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60 seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of uterine activity. Irregular and mild contractions are common in the latent phase.

Excessive anxiety during labor heightens the clients sensitivity to pain by increasing: a.muscle tension. b.the pain threshold. c.blood flow to the uterus. d.rest time between contractions.

A Anxiety and fear increase muscle tension, diverting oxygenated blood to the womans brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets between contractions.

An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates: a.lightening. b.breech presentation. c.urinary tract infection. d.onset of Braxton-Hicks contractions.

A As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

Which clinical findings would be considered to be normal for a preterm fetus during the labor period? a.Baseline tachycardia b.Baseline bradycardia c.Fetal anemia d.Acidosis

A Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

To determine if the client is in true labor, the nurse would assess for changes in: a.cervical dilation. b.amount of bloody show. c.fetal position and station. d.pattern of uterine contractions.

A Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor.

Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should: a.maintain the normal assessment routine. b.administer O2 at 8 to 10 L/min by face mask. c.increase the IV flow rate from 125 to 150 mL/hr. d.assess the maternal blood pressure for a systolic pressure below 100 mm Hg

A Decelerations that mirror the contraction are early decelerations caused by fetal head compression. Early decelerations are not associated with fetal compromise and require no intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are not necessary in early decelerations.

The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a.Doppler b.Fetoscope c.Scalp electrode d.Tocodynamometer

A Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions.

Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by: a.expanding the maternal blood volume. b.maintaining a normal maternal temperature. c.preventing normal maternal hypoglycemia. d.increasing the oxygen-carrying capacity of the maternal blood.

A Filling the mothers vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not add extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

A laboring client who imagines her body opening to let the baby out is using a mental technique called: a.imagery. b.effleurage. c.distraction. d.dissociation.

A Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working.

The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patients contractions. How will the nurse document these findings? a.Late decelerations b.Early decelerations c.Variable decelerations d.Proximal decelerations

A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contractions peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal decelerations is not a recognized term.

The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a.Administer oxygen with a face mask at 8 to 10 L/min. b.Reposition the fetal monitor ultrasound transducer. c.Assist the client to the bathroom to empty her bladder . d.Continue to monitor the client and fetal heart rate patterns.

A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. They reflect possible impaired placental exchange (uteroplacental insufficiency). Administration of 100% oxygen through a snug face mask makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10 L/min. The pattern is nonreassuring so repositioning the fetal ultrasound transducer, assisting the client to the bathroom, or continuing to monitor the pattern will not correct the problem.

After birth of the placenta the patient states, All of a sudden I feel very cold. What is the best nursing action in response to this statement? a.Place a warm blanket over the patient. b.Place the baby on the patients abdomen. c.Tell the patient that chills are expected after birth. d.What do you mean by your words very cold?

A Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary.

The primary difference between the labor of a nullipara and that of a multipara is: a.total duration of labor. b.level of pain experienced. c.amount of cervical dilation. d.sequence of labor mechanisms.

A Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors.

A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated with opiate-dependent patients? a.Nalbuphine (Nubain) b.Hydroxyzine (Vistaril) c.Promethazine (Phenergan) d.Diphenhydramine (Benadryl)

A Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics.

A client received 25 mg of meperidine (Demerol) intravenously 1 hour before birth. Which drug should the nurse have readily available? a.Naloxone (Narcan) b.Butorphanol (Stadol) c.Nalbuphine (Nubain) d.Promethazine (Phenergan)

A Naloxone (Narcan) reverses narcotic-induced respiratory depression, which may occur with the administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics given to women in labor.

A client is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or do procedures? a.After the contraction is over b.When it is all right with the coach c.During increment of next contraction d.After administration of analgesic-anesthetic

A Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in the woman, preventing her from answering questions correctly.

A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement? a.The acme b.The interval c.The increment d.The decrement

A The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.

The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability. What is the priority action based on these findings? a.Document the findings. b.Contact the health care provider. c.Increase the rate of the existing IV to 200 mL/hr as per the standing prescription. d.Place oxygen via a rebreather mask at 10 L/min as per the standing prescription.

A The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a.Latent phase b.Active phase c.Second stage d.Transition phase

A The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time.

In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? a.The fetus is at 30 weeks of gestation. b.The mother has a history of fast labors. c.The mother has been given an epidural block. d.The mother has mild preeclampsia but is not in labor.

A The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR with an epidural is not considered an expected outcome. Preeclampsia should not cause a normal elevation of the FHR.

A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client? a.This results from molding. b.This results from lightening. c.This results from the fetal lie. d.This results from the fetal presentation.

A The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

A labor client has brought in with her a picture of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of: a.focal point. b.distraction. c.effleurage. d.relaxation.

A The use of a focal point (image and/or point reference in the labor room) is an example of nonpharmacologic pain control during labor. The image of the clients children is not serving as a method of distraction. Effleurage is the use of massage techniques to minimize pain perception. The image of the clients children is not serving as a method of relaxation.

A patient at 41 weeks gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurses priority action? a.Stop the infusion of Pitocin. b.Reposition the patient from her right to her left side. c.Perform a vaginal exam to assess for a prolapsed cord. d.Prepare the patient for an emergency cesarean section.

A There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. The presence of two or more nonreassuring fetal heart rate patterns increases the level of concern.

Which maternal condition should be considered a contraindication for the application of internal monitoring devices? a.Unruptured membranes b.Cervix dilated to 4 cm c.Fetus has known heart defect d.External monitors currently being used

A To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A compromised fetus should be monitored with the most accurate monitoring devices. The external monitor can be discontinued after the internal ones are applied.

Which of the following clients could be a candidate for a vaginal birth after cesarean section (VBAC)? a.A 32-year-old gravida 2, para 1, who had a primary cesarean section for fetal distress b.A 23-year-old gravida 3, para 2, who had two cesarean sections with classic incisions c.An 18-year-old gravida 3, para 2, who had cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively d.A 25-year-old gravida 1, para 0, who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth

A VBAC can be done if the need for the primary cesarean section was based on factors other than cephalopelvic disproportion (CPD) and macrosomia. A client who has had a prior classic incision into the uterus is not a candidate for this type of procedure. Based on the presented history of a cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively, this client is at risk for uterine rupture and for delivering another macrosomic infant because she has already had two cesarean sections for the same indications. A client who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth is not a candidate for a VBAC because she does not meet the clinical criteria.

The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurses priority action for this patient? a.Ask the patients labor coach if this is a usual expression of pain for her. b.Refer to the patients chart to determine any orders for pain medication. c.Tell the patient that she is disturbing the other laboring patients on the unit. d.Encourage the patient to try to suppress her noisiness during contractions

A Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a womans personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a womans individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others.

The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) a.Offer the client a warm blanket. b.Place an ice pack on the perineum. c.Massage the uterus if it is boggy. d.Delay breastfeeding until the client is rested. e.Explain to the client that the lochia will be light pink in color.

A,B,C The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.) a.Oxytocin (Pitocin) b.Misoprostol (Cytotec) c.Dinoprostone (Cervidil) d.Methylergonovine maleate (Methergine)

A,B,C,D Oxytocin, misoprostol, and dinoprostone fall under the general category of uterine stimulants. Cytotec and Cervidil are prostaglandins. Methergine is an ergot alkaloid.

While developing an intrapartum care plan for the client in early labor, it is important that the nurse recognize that psychosocial factors may influence a womans experience of pain. These include which of the following? (Select all that apply.) a.Culture b.Anxiety and fear c.Support systems d.Preparation for childbirth e.Previous experiences with pain

A,B,C,D,E Culture: A womans sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a womans ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Support systems: An anxious partner is less able to provide help and support to a woman during labor. A womans family and friends can be an important source of support if they convey realistic and positive information about labor and birth. Preparation for childbirth: This does not ensure a pain-free labor. Preparation does reduce anxiety and fear. It also allows a woman to rehearse for labor. Previous experiences with pain: Fear and withdrawal are natural responses to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience.

When evaluating the clients progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are (select all that apply): a.baroreceptors. b.adrenal glands. c.chemoreceptors. d.uterine activity. e.autonomic nervous system.

A,B,C,E The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, whereas parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing accelerations in FHR. Hypertonic uterine activity can reduce the time available for the exchange of oxygen and waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and decrease when the fetus sleeps.

Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) a.A gush of blood appears. b.The uterus rises upward in the abdomen. c.The fundus descends below the umbilicus. d.The cord descends further from the vagina. e.The uterus becomes boggy and soft, with an elongated shape.

A,B,D Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected.

The nurse is preparing a client for a cesarean section scheduled to be done under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?(Select all that apply.) a.Citric acid (Bicitra) b.Ranitidine (Zantac) c.Hydroxyzine (Vistaril) d.Glycopyrrolate (Robinul) e.Promethazine (Phenergan)

A,B,D To prevent aspiration of gastric contents during general anesthesia administration of medications to raise the gastric pH and make secretions less acidic, such as citric acid (Bicitra) and ranitidine (Zantac) may be prescribed. In addition, medications to reduce secretions, such as glycopyrrolate (Robinul) may be prescribed. Hydroxyzine (Vistaril) and promethazine (Phenergan) are used to prevent and relieve nausea often associated with opioids.

The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.) a.Powers b.Passage c.Position d.Passenger e.Psyche

A,B,D,E Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor. Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the womans ability to cope. Position is not one of the four Ps.

The nurse is preparing supplies for an amnioinfusion on a client with intact membranes. Which supplies should the nurse gather? (Select all that apply.) a.Extra underpads b.Solution of 3% normal saline c.Amniotic hook to perform an amniotomy d.Solid intrauterine pressure catheter with a pressure transducer on its tip

A,C Amnioinfusion is performed with lactated Ringers solution or normal saline, not 3%. Normal saline is infused into the uterus through an intrauterine pressure catheter (IUPC). The underpads must be changed regularly because fluid leaks out constantly. The membranes need to be ruptured before an amnioinfusion can be initiated so an amniotic hook will be needed. The IUPC must have a double lumen to run the infusion through.

The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a.Soft boggy uterus b.Maternal temperature of 99 F c.High uterine fundus displaced to the right d.Intense vaginal pain unrelieved by analgesics e.Half of a lochia pad saturated in the first hour after birth

A,C,D Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a.Maternal hypotension b.Fetal heart rate of 140 to 150 bpm c.Meconium-stained amniotic fluid d.Maternal fever38 C (100.4 F) or higher e.Complete uterine relaxation of more than 30 seconds between contractions

A,C,D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38 C [100.4 F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a.Sitz baths four times a day b.Use of only warm water with the sitz baths c.Topical anesthetic spray after perineal care d.Ice pack to the perineum for the first 24 hours e.Sitting while relaxing the perineal and buttock areas

A,C,D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.) a.In true labor, the cervix begins to dilate. b.In true labor, the contractions are felt in the abdomen and groin. c.In true labor, contractions often resemble menstrual cramps during early labor. d.In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages. e.In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

A,C,E In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking. False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in frequency, duration, and intensity.

A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.) a.Ask her if her if she thinks that her membranes have ruptured. b.Ask her if she has any evidence of bloody show. c.Have her keep monitoring her contraction pattern and call you back if they become more regular. d.Ask her when her she has her next scheduled visit with her health care provider. e.Tell her to come into the hospital for evaluation.

A,E The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor.

A multiparas labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request? a.Maternal pulse b.Maternal temperature c.Maternal blood pressure d.Maternal blood glucose level

B A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several studies have shown benefits of water therapy during labor, including immersion in a tub or whirlpool (jet hydrotherapy, or Jacuzzi). The major concern about immersion therapy has been newborn and postpartum maternal infections caused by microorganisms in the water. Infections can be caused by the womans own ascending vaginal bacteria or by preexisting organisms in an improperly cleaned tub. However, several studies have not found a significant association between newborn or postpartum maternal infections and the use of immersion hydrotherapy with proper cleaning.

The priority intervention for a client with epidural anesthesia whose blood pressure is 80/50 mm Hg is: a.reposition to supine position. b.administer ephedrine, 5 mg IV push. c.maintain IV infusion rate at 150 mL/hr. d.Notify anesthesia about maternal hypotension.

B A significant blood pressure decrease is a drop to 100 mm Hg or lower systolic. If hypotension is significant, ephedrine is ordered to increase the blood pressure to normal values. The supine position will further decrease maternal blood pressure by compressing the major vessels. Maintaining the IV infusion rate will not return blood pressure to normal values as quickly as needed; immediate action needs to be taken, and notifying anesthesia would be time-consuming.

A client is receiving oxytocin (Pitocin) to induce labor. The uterine contractions have become persistently hypertonic and the infusion is stopped. The health care provider has prescribed a tocolytic to stop contractions. Which medication should the nurse be prepared to administer? a.Naloxone (Narcan) b.Terbutaline (Brethine) c.Ephedrine d.Diphenhydramine (Benadryl)

B A tocolytic drug, such as terbutaline (0.125 to 0.25 mg IV or 0.25 mg subcutaneously), may be given to reduce uterine activity. Narcan is a narcotic antagonist. Benadryl is an antihistamine. Ephedrine is a vasopressor used to increase blood pressure.

On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time? a.Perform a vaginal exam to denote progress. b.Notify the health care provider. c.Initiate parenteral therapy. d.Apply oxygen via nasal cannula at 8 L/min.

B A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.

The physician has ordered an amnioinfusion for the laboring client. What data supports the use of this therapeutic procedure? a.Presenting part not engaged b.+4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) c.Breech position of fetus d.Twin gestation

B Amnioinfusion is a procedure used during labor when cord compression or the detection of gross meconium staining is found in the amniotic fluid. A saline solution is used as an irrigation method through the IUPC (intrauterine pressure catheter).

The primipara at 39 weeks gestation states to the nurse, I can breathe easier now. What is the nurses best response? a.You labor will start any day now since the baby has dropped. b.That process is called lightening. Do you have to urinate more frequently? c.Contact your health care provider when your contractions are every 5 minutes for 1 hour. d.You will likely not feel you babys movements as much now, so do not be concerned.

B As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patients statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority intervention should be done by the nurse to help evaluate clinical response to treatment? a.Obtain a pain scale response from the client based on a 0 to 10 scale. b.Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. c.Document intake and output on the electronic health record (EHR). d.Increase the flow rate of prescribed parenteral fluid to maintain hydration

B Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this clients situation. Increasing the flow rate of parenteral fluids requires a physicians order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.

A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration? a.Oxytocin (Pitocin) b.Naloxone (Narcan) c.Bromocriptine (Parlodel) d.Oxygen

B Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression.

Childbirth pain is different from other types of pain in that it is: a.less intense. b.associated with a physiologic process. c.more responsive to pharmacologic management. d.designed to make one withdraw from the stimulus.

B Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during labor may affect the course and length of labor. The pain with childbirth is a normal process; it is not caused by the type of injury as when withdrawal from the stimulus occurs.

Your laboring client has asked that you help her to use a cutaneous stimulation strategy for pain management, you would then: a.assist her into the shower. b.apply a heat pack to lower back. c.help her to create a relaxing mental scene. d.encourage cleansing breaths and slow-paced breathing.

B Cutaneous stimulation includes self-massage, massage by others, counterpressure, touch, thermal stimulation, and acupressure. A shower, tub, or whirlpool are forms of hydrotherapy; creating a relaxed mental scene is mental stimulation. The use of cleansing breaths and patterned breathing is part of breathing techniques for labor.

The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase? a.The client is sociable and excited. b.The client is requesting pain medication. c.The client begins to experience the urge to push. d.The client experiences loss of control and irritability.

B During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a.Extension b.Engagement c.Internal rotation d.External rotation

B Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a.Every 15 minutes b.Every 30 minutes c.Every 45 minutes d.Every 1 hour

B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

Which client will most likely have increased anxiety and tension during labor? a.Gravida 2 who refused any medication b.Gravida 2 who delivered a stillborn baby last year c.Gravida 1 who did not attend prepared childbirth classes d.Gravida 3 who has two children younger than 3 years

B If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect.

Which fetal position may cause the laboring client more back discomfort? a.Left occiput anterior b.Left occiput posterior c.Right occiput anterior d.Right occiput transverse

B In the left occiput posterior position, each contraction pushes the fetal head against the mothers sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position.

When giving a narcotic to a laboring client, which statement explains why the nurse should inject the medication at the beginning of a contraction? a.The medication will be rapidly circulated. b.Less medication will be transferred to the fetus. c.The maternal vital signs will not be adversely affected. d.Full benefit of the medication is received during that contraction.

B Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus.

The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient? a.On her back b.On her left side c.On her right side d.On her hands and knees

B LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus. Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are present, there is no need to implement this position.

Which is the most appropriate method of intrapartum fetal monitoring when a woman has a history of hypertension during pregnancy? a.Continuous auscultation with a fetoscope b.Continuous electronic fetal monitoring c.Intermittent assessment with a Doppler transducer d.Intermittent electronic fetal monitoring for 15 minutes each hour

B Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications.

Which statement correctly describes the nurses responsibility related to electronic monitoring? a.Report abnormal findings to the physician before initiating corrective actions. b.Teach the woman and her support person about the monitoring equipment and discuss any of their questions. c.Document the frequency, duration, and intensity of contractions measured by the external device. d.Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.

B Teaching is an essential part of the nurses role. Corrective actions should be initiated first to correct abnormal findings as quickly as possible. Electronic monitoring will record the contractions and FHR response. The support person should still be encouraged to assist with the comfort measures.

A client whose cervix is dilated to 5 cm is considered to be in which phase of labor? a.Latent phase b.Active phase c.Second stage d.Third stage

B The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

The assessment finding which indicates that the client is in the active phase of the first stage of labor is: a.80% effacement. b.dilation of 5 cm. c.presence of bloody show. d.regular contraction every 3 to 4 minutes.

B The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined.

Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a.Station b.Flexion c.Descent d.Engagement

B The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet

Which event is the best indicator of true labor? a.Bloody show b.Cervical dilation and effacement c.Fetal descent into the pelvic inlet d.Uterine contractions every 7 minutes

B The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

Which nursing action is correct when initiating electronic fetal monitoring? a.Lubricate the tocotransducer with an ultrasound gel. b.Securely apply the tocotransducer with a strap or belt. c.Inform the client that she should remain in the semi-Fowler position. d.Determine the position of the fetus before attaching the electrode to the maternal abdomen.

B The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately. The tocotransducer does not need gel to operate appropriately. The client should be encouraged to move around during labor. The tocotransducer should be placed at the fundal area of the uterus.

The health care provider for a laboring patient makes the following entry into the patients record: 3/50%/1. What instruction will the nurse implement with the patient? a.You will need to remain in bed attached to the electronic fetal monitor. b.Breathe with me slowly, in through your nose and out through your mouth. c.I will begin the administration of 1000 mL of IV fluid so you can have an epidural. d.Your partner will need to change into scrub attire to attend the imminent birth.

B This client is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the stem that the membranes are ruptured, which may prohibit the patient from ambulating. Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at 1 station. Epidural placement during early labor may slow down the labor process. There is no indication that birth is imminent because the patient is 3 cm dilated.

What is the most likely cause for this fetal heart rate pattern? a.Administration of an epidural for pain relief during labor b.Cord compression c.Breech position of fetus d.Administration of meperidine (Demerol) for pain relief during labor

B Variable deceleration patterns are seen in response to head compression or cord compression. A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly, administration of medication and/or an epidural would not cause this fetal heart rate pattern.

A laboring patient states to the nurse, I have to push! What is the next nursing action? a.Contact the health care provider. b.Examine the patients cervix for dilation. c.Review with her how to bear down with contractions. d.Ask her partner to support her head with each push.

B When the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed.

The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that hes doing now, he could tell her when the contractions are: a.2 minutes apart. b.at their acme. c.at their increment. d.at their decrement.

B When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity.

When the mothers membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a.Early decelerations b.Variable decelerations c.Nonperiodic accelerations d.Increase in baseline variability

B When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes.

You are preparing a client for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.) a.Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement. b.Have ephedrine available at bedside during catheter placement. c.Monitor blood pressure of client frequently during catheter insertion and for the first 15 minutes of epidural administration. d.Insert a Foley catheter prior to epidural catheter placement. e.Monitor the client for hypertension in response to epidural insertion.

B,C A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is.

The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.) a.Progesterone levels become higher than estrogen levels. b.Natural oxytocin in conjunction with other substances plays a role. c.Stretching, pressure, and irritation of the uterus and cervix increase. d.The secretion of prostaglandins from the fetal membranes decreases.

B,C Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labors initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.) a.Post-term fetus b.Maternal fever c.Placenta previa d.Induction of labor e.Prolonged rupture of membranes

B,C,E Fetal scalp stimulation is not done when there is maternal fever (possibility of introducing microorganisms into the uterus), placenta previa (placenta overlies the cervix, and hemorrhage is likely), or prolonged rupture of membranes (risk of infection). Fetal scalp stimulation may be used to evaluate a post-term fetus response to stimulation. It is also used to evaluate a fetus when labor is being induced.

Which can be determined only by electronic fetal monitoring? a.Variability b.Tachycardia c.Bradycardia d.Fetal response to contractions

Beat-to-beat variability cannot be determined by auscultation because auscultation provides only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR monitoring techniques. The fetal response to the contractions is usually noted by an increase or decrease in fetal heart rate. These can be determined by any of the FHR monitoring techniques.

Which assessment finding would cause a concern for a client who had delivered vaginally? a.Estimated blood loss (EBL) of 500 mL during the birth process b.White blood cell count of 28,000 mm3 postbirth c.Client complains of fingers tingling d.Client complains of thirst

C A clients complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels.

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n): a.local. b.epidural. c.pudendal. d.spinal block.

C A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes. The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment? a.Use contact anesthesia for an epidural and prepare the client per protocol. b.Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop. c.Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. d.Call the physician for admitting orders.

C By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the clients needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the clients concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician.

To relieve a mild postdural puncture headache, the nurse should encourage the intake of: a.milk. b.orange juice. c.tea or coffee. d.beef or chicken bouillon.

C Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine.

An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is: a.onset of irregular contractions. b.cephalic presentation at 0 station. c.bloody mucus drainage from vagina. d.fetal heart tones (FHTs) present in the lower right quadrant.

C Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening.

Which of the following is the priority intervention for a supine client whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? a.Increase IV infusion. b.Elevate lower extremities. c.Reposition to left side-lying position. d.Administer oxygen per face mask at 4 to 6 L/min.

C Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the client is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the client is in a supine position.

Which clinical effect can occur in the presence of increased maternal pain perception during labor? a.Increase in uterine contractions in response to catecholamine secretion b.Decrease in blood pressure in response to alpha receptors c.Decreased perfusion to the placenta in response to catecholamine secretion d.Increased uterine blood flow, causing increase in maternal blood pressure

C Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure.

The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions? a.Assess the strongest intensity of each contraction. b.Assess uterine relaxation between two contractions. c.Assess from the beginning to the end of each contraction. d.Assess from the beginning of one contraction to the beginning of the next.

C Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction? a.Is not significantly affected b.Increases as blood pressure decreases c.Diminishes as the spiral arteries are compressed d.Continues except when placental functions are reduced

C During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

The nurse admits a laboring patient at term. On review of the prenatal record, the patients pregnancy has been unremarkable and she is considered low risk. In planning the patients care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? a.Every 10 minutes b.Every 15 minutes c.Every 30 minutes d.Every 60 minutes

C Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage.

To clarify the fetal condition when baseline variability is absent, the nurse should first: a.monitor fetal oxygen saturation using fetal pulse oximetry. b.notify the physician so that a fetal scalp blood sample can be obtained. c.apply pressure to the fetal scalp with a glove finger using a circular motion. d.Increase the rate of nonadditive IV fluid to expand the mothers blood volume.

C Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in response to the massage suggests that the fetus is in normal oxygen and acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer available in the United States. Obtaining a fetal scalp blood sample is invasive and the results are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the fetal condition.

Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? a.External fetal monitoring (EFM) b.Internal fetal monitoring c.Intrauterine pressure catheter (IUPC) d.Maternal comments based on perception

C IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength. EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and contraction pattern. It only estimates uterine contraction strength. Maternal comments related to pain may not be related to uterine contraction strength and thus are influenced by the clients own pain perception.

If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? a.Right upper b.Left upper c.Right lower d.Left lower

C If the fetus is in a right occiput anterior position, the fetal spine will be on the mothers right side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be in the right lower quadrant. The right upper, left upper, and left lower areas are not the best locations for assessing the fetal heart rate in this case.

The nurse assess a laboring patients contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern? a.Stage 1, latent phase b.Stage 2, latent phase c.Stage 1, active phase d.Stage 2, active phase

C In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage 2, latent phase, the woman is resting and preparing to push; she likely has not experienced the Ferguson reflex. She is actively bearing down during the active phase of the second stage.

If a notation on the clients health record states that the fetal position is LSP, this means that the: a.head is in the right posterior quadrant of the pelvis. b.head is in the left anterior quadrant of the pelvis. c.buttocks are in the left posterior quadrant of the pelvis. d.buttocks are in the right upper quadrant of the abdomen.

C LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT.

Client is at 38 weeks gestation, gravida 1, para 0, vaginal exam4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern? a.Continue oxytocin (Pitocin) infusion. b.Contact the anesthesia department for epidural administration. c.Change maternal position. d.Administer Narcan to client and prepare for immediate vaginal delivery.

C Late decelerations indicate fetal compromise (uteroplacental insufficiency) and are considered to be a significant event requiring immediate assessment and intervention. Of all the options listed, changing maternal position may increase placental perfusion. In the presence of late decelerations, Pitocin infusion should be stopped. Contacting anesthesia for epidural administration will not solve the existing problem of late decelerations. There are no data to support the administration of Narcan and because client is still in early labor, birth is not imminent.

The method of anesthesia in labor that is considered the safest for the fetus is: a.epidural block. b.pudendal block. c.local infiltration. d.spinal (subarachnoid) block.

C Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension.

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? a.Reposition the client. b.Apply a fetal scalp electrode. c.Record this reassuring pattern. d.Administer oxygen by nasal cannula.

C The periodic pattern described is early deceleration that is not associated with fetal compromise and requires no intervention. It is a reassuring pattern. Repositioning the client, applying a fetal scalp electrode, or administering oxygen would be interventions done for nonreassuring patterns.

When a nonreassuring pattern of the fetal heart rate is noted and the client is lying on her left side, which nursing action is indicated? a.Lower the head of the bed. b.Place a wedge under the left hip. c.Change her position to the right side. d.Place the mother in Trendelenburg position.

C Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. Lowering the head of the bed would not be the first position change choice. The woman is already on her left side, so a wedge on that side would not be an appropriate choice. Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted; the Trendelenburg position might be the choice.

The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing: a.a worsening hypoxia. b.progressive acidosis. c.a reassuring response. d.parasympathetic stimulation.

C The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) baseline. An increase in the FHR with stimulation does not indicate hypoxia. An increase in the FHR after stimulation is reassuring and does not indicate acidosis. An increase in the FHR after stimulation is a reassuring pattern and does not indicate problems with the parasympathetic nervous system.

Which client will be most receptive to teaching about nonpharmacologic pain control methods? a.Gravida 1, para 0, in transition b.Gravida 2, para 1, admitted at 8 cm c.Gravida 1, para 0, dilated 2 cm, 80% effaced d.Gravida 3, para 2, complaining of intense perineal pressure

C The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Clients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a client whose birth is imminent.

Which statement is true with regard to the type of pain associated with childbirth experience? a.Pain is constant throughout the labor experience. b.Labor pain during childbirth is considered to be an abnormal response. c.Pain associated with childbirth is self-limiting. d.Pain associated with childbirth does not allow for adequate preparation.

C The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a normal response during childbirth. Pregnant woman can prepare for the expected pain of childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor.

Meperidine (Demerol), 50 mg IV, has been ordered for a laboring patient. The patient is contracting every 3 minutes, with a duration of 45 to 60 seconds. What is the nurses best plan for administering the IV medication? a.Inject the medication between two contractions. b.Inject the medication during and after a single contraction. c.Inject the medication at the start of the next two contractions. d.Inject the medication throughout the duration of a single contraction.

C The suggested administration of IV Demerol is 25 mg/min and therefore will need to be administered over the course of two contractions. Opioid analgesics are given in small frequent doses by the IV route during labor to provide a rapid onset of analgesia and predictable duration of action. The woman will benefit from rapid pain control, with less likelihood of neonatal respiratory depression. Starting the injection at the beginning of the contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. When placental blood flow resumes, more of the drug is in maternal tissues.

Proper placement of the tocotransducer for electronic fetal monitoring is: a.inside the uterus. b.on the fetal scalp. c.over the uterine fundus. d.over the mothers lower abdomen.

C The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area.

A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention? a.Perform a vaginal exam to denote progress. b.Reposition the client to a side lying position. c.Instruct the client to breathe into her cupped hands. d.Notify the physician about current findings.

C This client is exhibiting signs of hyperventilation associated with a rapid breathing pattern, which can occur during the labor process. The nurse should instruct the client to breathe into her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process. A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in labor progress. Repositioning the client may be an option but is not the priority intervention at this time. Notifying the physician is not appropriate at this time because the RN should attend to actions that are readily available to her based on her scope of practice and standard of care. The physician may have to be notified once the intervention has been performed.

A client in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with: a.visceral pain. b.tissue ischemia. c.somatic pain. d.cervical dilation.

C This is an example of somatic pain experienced as a result of distention of the vagina and perineum during the second stage of labor. Visceral pain occurs in response to pressure on pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the uterus. The pain of cervical dilation is a major pain source during labor but, during the second stage of labor, the client is already fully dilated so this would not be a factor.

The process of labor places significant metabolic demands on the obstetric client. Which physiologic findings would be expected? a.Decreased maternal blood pressure as a result of stimulation of alpha receptors b.Uterine vasoconstriction as a result of stimulation of beta receptors c.Increased maternal demand for oxygen d.Increased blood flow to placenta because of catecholamine release

C With regard to labor, one would expect to see an increase in maternal blood pressure because of stimulation of alpha receptors. Uterine vasoconstriction would occur in response to stimulation of alpha receptors. One would expect to see a decrease in blood flow to the placenta. The maternal metabolic rate is increased during labor, along with an increase in maternal demand for oxygen.

Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have: a.a higher hematocrit. b.increased leukocytes. c.increased blood volume. d.a lower fibrinogen level.

C Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) a.Encourage the client to drink fluids. b.Place the client in a Trendelenburg position. c.Administer a normal saline bolus as prescribed. d.Administer oxygen at 8 to 10 L/min per face mask. e.Administer IV ephedrine in 5- to 10-mg increments as prescribed.

C,D,E If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client.

The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? a.This pattern reflects variable decelerations. No interventions are necessary at this time. b.Document this reassuring fetal heart rate pattern but decrease the rate of the intravenous (IV) fluid. c.Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. d.This deceleration pattern is associated with uteroplacental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply.

D A pattern similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the client on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a reassuring pattern, so the IV rate should be increased to increase the mothers blood volume. These are late decelerations, not early; therefore, interventions are necessary.

The primary side effect of maternal narcotic analgesia in the newborn is: a.tachypnea. b.bradycardia. c.acrocyanosis. d.respiratory depression.

D An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics.

The nurse is concerned that a clients uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? a.Reposition the tocotransducer. b.Reposition the Doppler transducer. c.Obtain an order from the health care provider for a spiral electrode. d.Obtain an order from the health care provider for an intrauterine pressure catheter.

D An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this would not be accurate with an obese client, even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral electrode) measures the fetal heart rate (FHR).

A major advantage of nonpharmacologic pain management is that: a.a more rapid labor is likely. b.more complete pain relief is possible. c.the woman remains fully alert at all times. d.there are no side effects or risks to the fetus.

D Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at a quicker pace. The womans alertness is not altered by medication, but the increase in pain will decrease alertness.

The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions? a.Vital signs taken during contractions are not accurate. b.During a contraction, assessing fetal heart rate is the priority. c.Maternal blood flow to the heart is reduced during contractions. d.Maternal circulating blood volume increases temporarily during contractions.

D During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by: a.promoting blood flow to the cervix. b.contracting the lower uterine segment. c.enlarging the internal size of the uterus. d.pulling the cervix over the fetus and amniotic sac.

D Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

Which client has the priority need for fetal monitoring? a.Primigravida at 38 weeks with spontaneous ROM b.Multigravida at 40 weeks with history of 10-hour labors c.Multigravida admitted for repeat elective cesarean section d.Primigravida at 39 weeks with meconium-stained amniotic fluid

D Meconium-stained amniotic fluid indicates a potential risk factor during labor. Primigravida at 38 weeks with spontaneous ROM, multigravida with a history of 10-hour labors, and multigravida admitted for repeat elective cesarean section do not have potential maternal or fetal risk factors.

Childbirth preparation can be considered successful if the outcome is described as which of the following? a.Labor was pain-free. b.The birth experiences of friends and families were ignored. c.Only nonpharmacologic methods for pain control were used. d.The client rehearsed labor and practiced skills to master pain.

D Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realistic information about labor pain. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone.

Uncontrolled maternal hyperventilation during labor results in: a.metabolic acidosis. b.metabolic alkalosis. c.respiratory acidosis. d.respiratory alkalosis.

D Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

A patient in active labor requests an epidural for pain management. What is the nurses priority action for this patient? a.Assess the fetal heart rate pattern over the next 30 minutes. b.Take the patients blood pressure every 5 minutes for 15 minutes. c.Determine the patients contraction pattern for the next 30 minutes. d.Initiate an IV infusion of lactated Ringers solution at 2000 mL/hr over 30 minutes.

D Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringers or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation.

A pregnant woman is in the second stage of labor and is actively pushing. What type of pain would she be most likely to experience? a.Deep, poorly localized pain b.Visceral pain c.Slow, dull, aching pain d.Somatic pain

D Somatic pain is quick, sharp, and precisely localized and is seen during the second stage of labor. Deep, poorly localized pain is associated with visceral pain, which predominates during the first stage of labor. Visceral pain is slow, deep, dull, aching, and poorly localized. Slow, dull, aching pain is characteristic of visceral pain.

Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation? a.Inhibition of epinephrine b.Inhibition of norepinephrine c.Stimulation of the vagus nerve d.Sympathetic stimulation

D Sympathetic nerve innervation would result in an increase in fetal heart rate. The release of epinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. The release of norepinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. Stimulation of the vagus nerve would indicate parasympathetic innervation and result in a decreased heart rate.

A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long? a.50 minutes b.hours c.6 to 7 hours d.8 to 10 hours

D The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 minutes for a nullipara. The transition phase lasts hours for a nullipara. A multiparas active phase of labor is 6 to 7 hours.

In which situation would it be appropriate to obtain a fetal scalp blood sample to establish fetal well-being? a.The fetus has developed tachycardia related to maternal fever. b.The mother has vaginal bleeding, and the baseline fetal heart rate is decreasing. c.The fetal heart tracing on a preterm fetus shows decreased baseline variability. d.The fetal heart tracing shows a persistent pattern of late decelerations, with normal baseline variability.

D The tracing is nonreassuring, and additional assessment is needed regarding the acid-base status of the fetus. Fetal scalp blood sampling is contraindicated with vaginal bleeding, maternal fever, and a preterm fetus

A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with: a.more rapid labor. b.a high risk of infection. c.maternal perineal trauma. d.umbilical cord compression.

D The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth.

Why is continuous electronic fetal monitoring generally used when oxytocin is administered? a.Fetal chemoreceptors are stimulated. b.The mother may become hypotensive. c.Maternal fluid volume deficit may occur. d.Uteroplacental exchange may be compromised.

D The uterus may contract more firmly and the resting tone may be increased with oxytocin use. This response reduces the entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk.

To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should: a.give the woman oxygen. b.turn the woman to the right side. c.decrease the intravenous infusion rate. d.place a wedge under the womans right hip.

D Tilting the womans pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. However, placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension.

When a pattern of variable decelerations occur, the nurse should: a.administer O2 at 8 to 10 L/min. b.place a wedge under the right hip. c.increase the IV fluids to 150 mL/hr. d.position client in a knee-chest position.

D Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The client should be repositioned when the FHR pattern is associated with cord compression. The knee-chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression.

The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a.Decrease the rate of the IV fluids. b.Document the fetal heart rate pattern. c.Explain to the client that the pattern is reassuring. d.Perform a vaginal exam to detect a prolapsed cord.

D Variable decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. A vaginal examination may identify a prolapsed cord, which may cause variable decelerations, bradycardia, or both as it is compressed. A vaginal examination also evaluates the womans labor status, which helps the birth attendant decide if labor should continue. This is a nonreassuring pattern so the IV rate should be increased and an intervention needs to be done, not just documentation.

A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session? a.It usually results in a more rapid labor. b.It has no effect on the outcome of labor. c.It is considered to be a normal occurrence. d.It may result in decreased placental perfusion.

D When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed.