Pregnancy Quiz
Which recommendation would the nurse make to a new breast-feeding mother who asks how to care for her nipples? 1-Put lanolin cream on the nipples after breast-feeding. 2-Apply vitamin E gel to the nipples before breast-feeding. 3-Use soap and water to clean the breasts and nipples at least once a day. 4-Spread breast milk on the nipples after the feeding and allow them to air-dry.
4-Spread breast milk on the nipples after the feeding and allow them to air-dry. Breast milk is a natural lubricant for the nipples and obviously is not toxic for the infant. Products containing lanolin or vitamin E are not recommended because these may be ingested by the infant. Soap should not be used on the nipples because it has a drying effect, which may precipitate cracking of the nipples
Which factor may alter the absorption of medications taken orally during pregnancy? 1-Delayed gastrointestinal emptying 2-A reduced glomerular filtration rate 3-Developing fetal-placental circulation 4-Increasing serum transaminases
1-Delayed gastrointestinal emptying Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and of the intestines laterally and posteriorly; absorption of some medications, vitamins, and minerals may be increased. The glomerular filtration rate increases during pregnancy and is unrelated to the absorption of medications. Developing fetal-placental circulation is unrelated to the absorption of medications. The serum transaminase levels are not affected by pregnancy.
Which is the position of the fetus whose buttocks are in the fundus, whose fetal back is on the maternal right side between the midline and lateral surface of the abdomen, and whose attitude is general flexion? 1-Right sacrum anterior (RSA) 2-Right occiput anterior (ROA) 3-Right mentoanterior (RMA) 4-Left occiput anterior (LOA
2-Right occiput anterior (ROA) The fetus is in the ROA position, with the occiput facing the front on the right side of the mother. It is a vertex delivery. In the RSA position, the buttocks point anteriorly on the mother's right side. RMA is a brow presentation. In LOA, another vertex position, the fetus's back is on the mother's left side.
Which is the priority nursing action for a client in the second stage of labor? 1-Check the fetus's position. 2-Administer medication for pain. 3-Promote effective pushing by the client. 4-Explain that breast-feeding can start right after birth
3-Promote effective pushing by the client. Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn's respirations. Although the mother may breast-feed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant.
Which is the initial nursing action when a multipara requests something for pain. 1-Examining the client's cervix for dilation and effacement 2-Determining the client's options by assessing the prescriptions in the chart 3-Asking her whether she prefers an epidural or something in her intravenous line 4-Evaluating the fetal monitoring strip to determine the frequency and duration of contractions
1-Examining the client's cervix for dilation and effacement Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum? 1-Small tears 2-Greenish-yellow amniotic fluid 3-Enlarging area of caput with each contraction 4-An increasing amount of amniotic fluid with each contraction
3-Enlarging area of caput with each contraction Rational The client should be pushing with each contraction; with the head at +3 station, each push will bring more of the caput into view at the vaginal opening. It is too early for the perineum to be stretched to the point of tearing; if this should occur later, an episiotomy may be performed. Meconium is discoloring the amniotic fluid; it is an unexpected finding that may indicate that the fetus is at risk. There is a decreased, not an increased, amount of amniotic fluid at the end of labor Physical assessment of a client
A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? (Select all that apply.) 1. The expelled fluid totals 500 mL. 2. The expelled fluid is light yellow. 3. The expelled fluid smells similar to urine. 4. Nitrazine paper turns blue on contact with the fluid. 5. Microscopic examination of the fluid reveals ferning/
4. Nitrazine paper turns blue on contact with the fluid. 5. Microscopic examination of the fluid reveals ferning
A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The nurse would direct the client to call back after taking which action? 1-Drink a glass of orange juice and time 10 fetal movements 2-Walk for 15 minutes and note if the fetus moves more frequently 3-Sit in a tub filled with warm water and then time 30 fetal movements 4-Rest with feet up and count the number of fetal movements for 20 minute
1-Drink a glass of orange juice and time 10 fetal movements Drinking orange juice can increase fetal movement. Fetal kick count, either the number counted in 30 minutes or the time it takes for 10 kicks to occur, is the accepted method of assessing the fetus for the appropriate amount of movement. Walking may increase fetal movement, but accuracy regarding the timing of the movements is needed to make an adequate assessment. Sitting in a tub of warm water may increase the client's sensitivity to fetal movements, but it is unnecessary to time 30 kicks. Lying quietly may increase the sensitivity to fetal movement, but movements must be counted for 30 minutes for an accurate assessment.
Initial vaginal examination reveals that a client's cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. Which is the correct documentation of this delivery? 1 Precipitous vaginal delivery 2 Prolonged transitional phase 3 Primigravida primary delivery 4 Normal spontaneous vaginal delivery
1-Precipitous vaginal delivery A delivery that takes less than 3 hours is considered precipitous. A multipara usually progresses at the rate of 1.5 cm of dilation per hour and must progress to 10 cm for delivery. The second stage, birth, usually averages approximately 20 minutes. A prolonged transitional phase would indicate that progression from 8 to 10 cm took longer than expected and would require augmentation. Primigravida means "first pregnancy," so this cannot be possible if the client is multiparous, having delivered before. Although this was a vaginal delivery, it was faster than average.
