OB FINAL STACK 1
26. Which finding on vaginal examination would be a concern if a spontaneous rupture of the membranes has occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d. Presenting part at + station
ANS: D If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.
5. The nurse is assisting the primary care provider with the third stage of a vaginal delivery. The patient is multiparous, experienced a precipitous birth, and has a history of hypertension. Which medical prescription does the nurse anticipate for this patient? 1. Methylergonovine 2. Fresh frozen plasma 3. Carboprost-tromethamine 4. Magnesium sulfate
ans 3 This is correct. Carboprost-tromethamine is classified as a prostaglandin and is prescribed to maintain contraction of the uterine muscles. It is injected into a large muscle or directly into the uterine muscle. The nurse will expect this prescription because the patient has multiple risks for PP
12. The nurse is providing care for a patient who is 1 day postpartum and exhibiting symptoms of postpartum psychosis. Which medical management does the nurse expect for this patient? 1. Prescriptions for antidepressant/antipsychotic drugs 2. Discharge to home with 24-hour observation in place 3. Immediate hospitalization in a psychiatric unit 4. Prescribed neonate visits during in-patient treatment
ans 3 This is correct. The nurse expects the health care provider to immediately hospitalize the patient in a psychiatric unit. Maintaining the patient in the postpartum unit delays necessary psychiatric treatment.
13. The nurse is aware of concern about the increasing numbers of severe maternal morbidity (SMM). It is believed to be related to changes in the overall health of the population of women giving birth. Which reasons does the nurse identify as causes of SMM? Select all that apply. 1. Increases in maternal age 2. Prepregnancy obesity 3. Cesarean deliveries 4. Inability to pay for health care 5. Preexisting chronic medical conditions
13. ANS: 1, 2, 3, 5
14. The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply. 1. Foul-smelling lochia 2. Hot, red, painful breasts 3. Mild headache 4. Not sleeping well 5. Frequent, painful urination
14. ANS: 1, 2, 5
15. A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient's medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply. 1. Neonatal macrosomia 2. Use of a vacuum extractor 3. Poor oral fluid intake 4. Urinary catheter during labor 5. Low-grade fever (101.3°F [38.5°C])
ANS: 1, 2, 3, 4
18. The nurse is collecting information during a follow-up OB appointment with a patient who delivered 3 months ago. The patient reports her partner has become cynical, irritable, and verbally abusive. The nurse will screen for which risks related to paternal postnatal depression (PPND)? Select all that apply. 1. The father exhibited depression during the pregnancy. 2. The birth of this fourth child was unexpected and unplanned. 3. The father expresses feeling bored and underappreciated in his job. 4. The father is recently estranged from his parents and siblings. 5. The mother experienced a prolonged labor and a cesarean birth.
ANS: 1, 2, 4
30. When reviewing the prenatal record of a patient at 42 weeks' gestation, the nurse recognizes that induction of labor is based upon which indication a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-lb weight gain at each of the last two weekly visits.
ANS: A Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-lb weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation
16. The nurse is assessing a patient who is 36 hours postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply. 1. Temperature increase from 99.8°F to 100.5°F 2. Incisional tenderness with palpation 3. Increased margins of incisional redness 4. Notably warm skin around the incision 5. Serosanguinous drainage from the suture line
ANS: 3, 4
36. After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse's concern regarding this risk? a. Hypovolemia b. Iron-deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency
ANS: C Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site
15. A patient who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "You should come into the office and let the doctor check you." b. "Acetaminophen is acceptable during pregnancy. You should not take aspirin, however." c. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."
ANS: A A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The patient needs to be assessed for preterm labor before providing pain relief.
8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs
ANS: A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.
32. Which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction
ANS: A A patient attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.
9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. palpate the infant's clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.
ANS: A Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.
11. Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.
ANS: D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may need to hold the presenting part away from the cord until delivery is complete.
12. A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the patient with her hips slightly elevated
ANS: A Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the patient at high risk for uterine rupture. The patient is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the patient with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.
6. Birth for the nulliparous patient with a fetus in a breech presentation is usually a. cesarean birth. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.
ANS: A Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.
34. Which patient is most at risk for a uterine rupture? a. A gravida 4 who had a classic cesarean incision b. A gravida 5 who had two vaginal births and one cesarean birth NURSINGTB.COM Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank NU RS IN GT B.CO M c. A gravida 3 who has had two low-segment transverse cesarean births d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant
ANS: A The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The patient who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Low-segment incisions do not raise the risk of uterine ruptures
5. Which technique is least effective for the patient with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees
ANS: B Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.
1. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent NURSINGTB.COM Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank NU RS IN GT B.CO M d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area
ANS: A, B, C, E Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.
28. Which finding would be indicative of an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL
ANS: B Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication
23. A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care? a. Administration of antihypertensive medication b. Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d. Internal fetal monitoring
ANS: B Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated. The patient with this condition will be hypotensive, not hypertensive.
19. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the patient not to push until you prepare the vacuum extraction device for physician. d. Reposition the patient to facilitate birth
ANS: B In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it may cause additional problems. Vacuum extraction will not help to resolve the birth issue and may lead to further complications. Repositioning of the patient may not be effective to relieve this condition and facilitate birth.
25. Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b. Fetal distress c. Maternal comfort during labor d. Irregular labor contraction pattern
ANS: B A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and patients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure.
4. A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position.
ANS: B A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.
14. The fetus in a breech presentation is often born by cesarean birth because a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the patient delivers vaginally.
ANS: B After the fetal legs and trunk emerge from the patient's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.
2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the patient is in active labor
ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinat
31. Which assessment finding in the postpartum patient following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b. Urine output >30 mL/hour c. Rebound skin turgor <5 seconds d. Pulse rate <120 beats/minute
ANS: B In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hour; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/minute may be indications of hypovolemia
1. Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid
ANS: B The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes
2. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.) a. Increased risk for placenta previa b. Painful uterine contractions c. Increased resting tone d. Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction
ANS: B, C, E Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus there is an increased risk for placental abruption as compared with placenta previa, which is based upon malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor
27. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/minute. b. Stop the Pitocin infusion. c. Position the patient in the knee-chest position. d. Increase the main line infusion to 150 mL/hour.
ANS: C A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.
3. A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2C (99F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates
ANS: C Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C (100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.
13. Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of -3 d. Meconium-stained amniotic fluid
ANS: C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the patient at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the patient at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.
20. A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test? a. Patient must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Patient should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.
ANS: C Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity
A dose of dexamethasone 12 mg was administered to a patient in preterm labor at 0830 hours on March 12. The nurse knows that the next dose must be scheduled for a. 1430 hours on March 12th. b. 2030 hours on March 12th. c. 0830 hours on March 13th. d. 1430 hours on March 13th.
ANS: C The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 1430 hours on March 12th, 2030 hours on March 12th, and 1430 hours on March 13th do not fall within this recommendation. The next dose should be scheduled for 0830 hours on March 13th
22. A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate? a. Vaginal birth with vacuum extraction b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d. Insertion of Foley catheter into empty bladder to provide more room for fetal descent
ANS: C The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the patient should be prepped for a cesarean section.
17. Which clinical finding during assessment indicates uterine rupture? a. Fetal tachycardia occurs. b. The patient becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.
ANS: D A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.
21. An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks' gestation and has two other children at home, ages 3 and 6. The patient's husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal? a. The patient and husband will be able to adapt their schedules accordingly to meet activities of daily living until the patient's next scheduled antepartum visit the following week. b. The patient and husband will hire a nanny to act as an additional caregiver for the next month. c. The patient will continue to take care of her children at home, taking frequent rest periods. d. The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.
ANS: D A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified timeframe. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the patient to take care of her children at home with rest period because the patient will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications.
16. Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure
ANS: D All assessments are important; however, those most relevant to tocolytic therapy include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured; however, these are not relevant to the medication
35. A pregnant woman develops hypertension. The nurse monitors the patient's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow
ANS: D Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension.
10. A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "Let me take off the monitor belts and help you get into a more comfortable position." c. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."
ANS: D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation, no matter at what stage. It is important to get her into a more comfortable position and fetal monitoring should continue. An alteration in breathing pattern will not decrease the pain in this situation.
7. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous patient with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous patient at 39 weeks of gestation who is expecting twins
ANS: D Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this patient's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
18. Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the patient for epidural administration as ordered by the physician
ANS: D The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore augmentation would not be advised at this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.
_ 7. The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take? 1. Continue to apply ice to the area for 24 hours. 2. Monitor vital signs and report any abnormal readings. 3. Contact the primary care provider for further evaluation. 4. Relieve pressure by placing patient in a side-lying position.
ans 3 This is correct. The primary care provider needs to be contacted about assessment findings; the hematoma may need to be evaluated further and/or evacuation of the hematoma performed.
4. The nurse continues to monitor a patient after a vaginal delivery with an estimated blood loss of 1,000 mL. Which assessment finding does the nurse recognize as requiring Stage 3 hemorrhage protocol? 1. Increased patient restlessness. 2. Manifestations of severe pain. 3. Development of abnormal vital signs. 4. Patient requests water for extreme thirst
ans 3 This is correct. Vital signs will remain normal during Stages 1 and 2. The evidence of abnormal vital signs is one indicator of Stage 3 hemorrhage. Other Stage 3 indicators include continued bleeding, more than 2 units red blood cells (RBCs) given, patient at risk for occult bleeding/coagulopathy, abnormal laboratory values, or oliguria
2. The nurse is aware the greatest source of bleeding during childbirth occurs following detachment of the placenta. Which physiological change takes place immediately after the expulsion of the placenta to decrease the amount of blood loss? 1. Contractions of the uterine myometrium 2. Factor VIII complex increases during gestation 3. Platelet activity increases before labor and delivery 4. Fibrin formation increases before the birth occurs
ans 1 This is correct. After placenta detachment, contractions of the myometrium compress the blood vessels at the placental site, thus decreasing the amount of blood loss
8. The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus? 1. Scant amount of odorless lochia 2. Presence of headache, malaise, and chills 3. Pain or discomfort in the midline lower abdomen 4. Elevated temperature greater than 100.4°F (38°C)
ans 1 This is correct. Endometritis from beta-hemolytic streptococcus specifically exhibits scant, odorless lochia in addition to the more universal signs of infection.
11. The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, "I think that my baby is deformed inside and we have to fix him." Which risk factor is most strongly related to possible postpartum psychosis (PPP)? 1. Separation from the baby's father 2. Personal history of bipolar disorder 3. Prolonged labor resulting in cesarean 4. Loss of first child from a heart defect
ans 2 This is correct. A patient history of either bipolar disorder or affective disorder can result in postpartum psychosis (PPP).
1. The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room? 1. Ask the patient how many peripads she considered to be "soaked." 2. Collect blood in calibrated, under-buttocks drapes for vaginal birth. 3. Place a basin at the foot of the delivery table to catch any blood. 4. Rely on the primary health care provider's estimate of blood loss
ans 2 This is correct. Collecting blood in calibrated, under-buttocks drapes for vaginal birth and then weighing the drapes is the easiest way to estimate blood loss in the delivery room
10. The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management? 1. Application of hot packs to the perineal area 2. Information applicable to medication therapy 3. Instructions to improve circulation by ambulating 4. Medicating for pain above level 4 on a 0 to 10 scale
ans 2 This is correct. The nurse will need to provide applicable discharge teaching for both antibiotic and analgesic therapy. Antibiotics need to be taken as ordered and until they are gone.
3. The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation? 1. Blood pressure may be elevated from prenatal conditions. 2. Respirations are increased due to activity of labor. 3. Changes in blood pressure may not be an immediate sign. 4. Heart rate may increase with intensity of labor
ans 3 This is correct. Changes in blood pressure may not be an immediate sign of hemorrhage in a postpartum patient. OB patients may not show the same signs and symptoms observed in nonpregnant patients during hemorrhage until approximately one-third of the woman's entire blood volume is lost. The postpartum patient has an increased blood volume from pregnancy, which delays vital sign indications. A decrease in BP is a late sign of postpartum hemorrhage.
9. The lactation nurse takes a phone call from a mother who is breastfeeding her 2-month-old infant. The mother reports an area of redness and warmth on the breast and a painful burning sensation when breastfeeding. Which statement by the nurse is correct if mastitis is suspected? 1. "If your nipples are cracked, you will need to stop breastfeeding." 2. "Pump your milk and throw it away until the infection is gone." 3. "The baby gave you an infection and needs to be on antibiotics." 4. "Continuing to breastfeed will help clear up the condition.
ans 4 This is correct. Mastitis is generally self-limiting, and continued breastfeeding can help clear up the infection and condition. If antibiotic therapy is indicated, the infection generally resolves within 24 to 48 hours of antibiotic therapy.
6. The nurse is closely monitoring a patient who is postpartum and at risk for PPH. Which assessment finding will cause the nurse to contact the primary care provider immediately? 1. The uterus is displaced. 2. The uterine fundus is boggy 3. Small clots are expressed with massage. 4. Peripad weighs 100 g within 15 minutes.
ans 4 This is correct. The nurse will monitor the amount and characteristics of each patient's lochia. If bleeding seems excessive, the nurse will weigh peripads to ascertain the amount of blood loss. This patient's EBL is 100 mL in 15 minutes (1 g = 1 mL of blood). The nurse will contact the primary care provider and report postpartum hemorrhage.