SAUNDERS MATERNITY: HEALTH PROBLEMS

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring

1. Uterine tenderness 2.Acute abdominal pain 3. A hard, "board-like" abdomen 5. Increased uterine resting tone on fetal monitoring Rationale:In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. Test-Taking Strategy(ies):Focus on the subject, the signs of abruptio placentae. Remember that the difference between placenta previa and abruptio placentae involves uterine pain and tenderness with an abruption as opposed to painless bleeding with a previa. Options 1, 2, 3, and 5 all describe the presence of abruptio placentae, whereas option 4 is the only choice that describes placenta previa.

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1.A primigravida with abruptio placenta 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 4.A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

1.A primigravida with abruptio placenta 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension Rationale:In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage. Test-Taking Strategy(ies):Note the strategic word, most. Focus on the subject, the client at most risk for DIC. Think about the pathophysiology associated with DIC and select the options that identify abnormal conditions. This will direct you to the correct options.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1.Age 54 years 2.Body mass index of 28 3.Previous difficulty with fertility 4.Administration of oxytocin for induction 5.Potassium level of 3.6 mEq/L (3.6 mmol/L)

1.Age 54 years 2.Body mass index of 28 3.Previous difficulty with fertility

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1.Delivery of the fetus 2.Strict monitoring of intake and output 3.Complete bed rest for the remainder of the pregnancy 4.The need for weekly monitoring of coagulation studies until the time of delivery

1.Delivery of the fetus Rationale:Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae. Test-Taking Strategy(ies):Focus on the subject, management of abruptio placentae. Use knowledge regarding the pathophysiology and management of abruptio placentae to answer the question. Note the words term gestation and moderate vaginal bleeding. Knowing that the goal is to deliver the fetus will direct you easily to the correct option.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1.Flushing 2.Hypertension 3.Increased urine output 4.Depressed respirations 5.Extreme muscle weakness 6.Hyperactive deep tendon reflexes

1.Flushing 4.Depressed respirations 5.Extreme muscle weakness Rationale:Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. Test-Taking Strategy(ies):Focus on the subject, adverse effects of magnesium sulfate. Recalling that this medication is a central nervous system depressant and relaxes smooth muscle will assist you in choosing the correct options.

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing? 1.Hypotonic 2.Precipitate 3.Hypertonic 4.Preterm labor

1.Hypotonic Rationale:Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation. Test-Taking Strategy(ies):Focus on the subject, the specific type of labor dystocia. Note the relationship between the words short, irregular, and weak in the question and hypotonic in the correct option.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1.Measure fundal height. 2.Attach electronic fetal monitoring. 3.Prepare the client for a possible cesarean section. 4.Visually examine the perineum and vaginal opening.

1.Measure fundal height. Measuring fundal height is least appropriate because it should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the primary health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix. Test-Taking Strategy(ies):Note the strategic words, least appropriate. Also, note that the client is in early labor. With this in mind, think about the nursing interventions associated with early labor and a breech presentation.

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1.Petechiae 2.Hematuria 3.Increased platelet count 4.Prolonged clotting times 5.Oozing from injection sites 6.Swelling of the calf of 1 leg

1.Petechiae 2.Hematuria 4.Prolonged clotting times 5.Oozing from injection sites DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. The presence of petechiae, hematuria, and oozing from injection sites are signs associated with DIC. Swelling and pain in the calf of 1 leg are more likely to be associated with thrombophlebitis. Test-Taking Strategy(ies):Note the strategic words, most likely. Think about the pathophysiology associated with DIC, and recall that DIC is a widespread problem rather than a localized one to direct you to the correct options.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Promote ambulation every 30 minutes. 4.Monitor the oxytocin infusion closely

1.Provide pain relief measures. Rationale:Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest. Test-Taking Strategy(ies):Focus on the strategic word, priority. Also note that options 2, 3, and 4 are comparable or alike and are therapeutic measures for hypotonic dysfunction.

The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources for which primary reason? 1.Reduce excessive maternal stress and fatigue. 2.Help the mother prepare for labor and delivery. 3.Avoid exposure to potential pathogens and resulting infections. 4.Prepare the 18-month-old child for maternal separation during hospitalization.

1.Reduce excessive maternal stress and fatigue. Rationale:A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The use of resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. These resources are not intended to minimize potential risk of maternal infection or prepare the client and family for the subsequent labor, delivery, and hospitalization. Test-Taking Strategy(ies):Focus on the subject, identifying resources for a pregnant client with cardiac disease and note the strategic word, primary. Focusing on the pathophysiology of the client's condition will assist in directing you to the correct option.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1.Supine position with a wedge under the right hip 2.Trendelenburg's position with the legs in stirrups 3.Prone position with the legs separated and elevated 4.Semi-Fowler's position with a pillow under the knees

1.Supine position with a wedge under the right hip Rationale:Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Test-Taking Strategy(ies):Focus on the subject, positioning the pregnant woman. Visualizing each of the positions identified in the options and considering the effect that the position may have on the mother and the fetus will direct you to the correct option.

The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? 1.The client's fear 2.The client's fatigue 3.The client's inability to control the situation 4.The client's inability to cope with the situation

1.The client's fear Rationale:The mother is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. There are no data in the question to support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience. Test-Taking Strategy(ies):Note the strategic words, most appropriate. When answering questions related to a client problem, focus specifically on the data provided in the question. Note the relationship between the word frightened in the question and fear in the correct option.

A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa? 1.The placenta is implanted in the lower uterine segment. 2.The greatest risk associated with this condition is chronic hypertension. 3.There are two placentas attached to the fetus located in the side of the uterine wall. 4.The placenta is half the size that it is expected to be, presenting a risk for deprivation of nutrients to the fetus.

1.The placenta is implanted in the lower uterine segment. Rationale:In placenta previa, there is one placenta that is normal size but is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus; therefore, the greatest risk associated with this condition is bleeding. Test-Taking Strategy(ies):Focus on the subject, the characteristics associated with placenta previa. Thinking about the pathophysiology associated with this disorder and noting the word previa will assist in answering correctly.

A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 37.2º C (99º F). The nurse plans care based on which interpretation? 1.The woman requires further evaluation for preterm labor. 2.The woman is suffering from an intestinal bacterial infection. 3.The woman is exhibiting signs and symptoms of gestational hypertension. 4.The woman needs instruction on pelvic tilts to decrease her lower back pain.

1.The woman requires further evaluation for preterm labor. Rationale:Classic signs and symptoms of preterm labor include lower abdominal cramping, possibly accompanied by diarrhea; dull and intermittent low back pain; painful menstrual-like cramps; suprapubic pain or pressure; pelvic pressure or heaviness; urinary frequency; change in character and amount of vaginal discharge; and rupture of amniotic membranes. Early recognition of preterm labor is essential, so interventions such as tocolytic therapy and administration of antenatal glucocorticoids can be initiated; therefore, further evaluation of the cervix, membrane status, uterine activity, and fetal heart rate is necessary to determine if the client is in preterm labor (the correct option). The client's temperature is only slightly elevated, and her diarrhea presents in addition to the signs and symptoms of preterm labor, so option 2 can be eliminated. The client is not exhibiting signs of gestational hypertension, so therefore eliminate option 3. Because the client has additional complaints that may possibly relate to preterm labor, instruction on pelvic tilts to decrease back pain is irrelevant at this time, so therefore eliminate option 4. Test-Taking Strategy(ies):Note the subject, analysis of clinical manifestations for a pregnant woman. Focus on the date of admission and the EDD of the client. This indicates the client's gestational age as being preterm. This will direct you to the correct option.

A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs? 1. "My weight gain is not important." 2. "I should avoid stressful situations." 3. "I should rest by lying on my back." 4. "There is no restriction on people who visit me."

2. "I should avoid stressful situations." Rationale:Stress causes increased heart workload, and the client should be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return and avoid supine hypotension. To avoid infections, individuals with active infections should not be allowed to visit the client. Otherwise, restrictions are not required. Test-Taking Strategy(ies):Focus on the subject, client instructions for the pregnant woman with heart disease. Note the words heart disease and she understands her needs in the question. Knowledge of principles related to the therapeutic management of cardiac disease in general and those activities that would exacerbate the condition will assist in directing you to the correct option.

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. 1. Use of diaphragm 2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID)

2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID) Rationale:An ectopic pregnancy is one that establishes itself somewhere other than inside the uterus. Multiple factors may predispose a woman to an ectopic pregnancy. Fertility medications, history of sexually transmitted infections, intrauterine devices, and PID have all been associated with ectopic pregnancy. There are no data to support any additional risk for ectopic pregnancy with the use of the diaphragm. Test-Taking Strategy(ies):Focus on the subject, predisposing factors for an ectopic pregnancy. Recognizing that a significant reason for ectopic pregnancies relates to tubal patency should lead you to the correct options.

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1."I will watch to see if I pass any tissue." 2."I will maintain strict bed rest throughout the remainder of the pregnancy." 3."I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4."I will avoid sexual intercourse until the bleeding has stopped and for 2 weeks following the last episode of bleeding."

2."I will maintain strict bed rest throughout the remainder of the pregnancy." Rationale:Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client should watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and the need to select an incorrect client statement. Noting the word strict in the correct option will assist in directing you to this option.

The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. 1.Soft uterus 2.Abdominal pain 3.Nontender uterus 4.Firm uterus by palpation 5.Painless vaginal bleeding

2.Abdominal pain 4.Firm uterus by palpation Rationale:Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized or diffuse over 1 region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa. Test-Taking Strategy(ies):Focus on the subject, manifestations of abruptio placentae. Recall that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with an abruption, as opposed to painless bleeding with placenta previa. Options 2 and 4 describe the presence of abruptio placentae, whereas options 1, 3, and 5 describe placenta previa.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1.Nalbuphine 2.Betamethasone 3.Rho(D) immune globulin 4.Dinoprostone vaginal insert

2.Betamethasone Rationale:Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions. Test-Taking Strategy(ies):Focus on the subject, a client at 31 weeks' gestation. Recall that the preterm infant is at risk for respiratory distress syndrome because of immaturity and the inability to produce surfactant. Next, recalling the actions of the medications in the options and that betamethasone is used to increase the production of surfactant will direct you to the correct option.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the primary health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1.Bear down. 2.Breathe rapidly. 3.Hold your breath. 4.Push with each contraction.

2.Breathe rapidly. Rationale:During a precipitous labor, when the infant's head crowns the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus. Test-Taking Strategy(ies):Note the subject, precipitous labor. Hold your breath can be eliminated first because this action decreases the amount of oxygen to the mother and to the fetus. Next, eliminate options 1 and 4 because they are comparable or alike.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? 1.Notify the primary health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.

2.Discontinue the infusion of oxytocin. Rationale:The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time. Test-Taking Strategy(ies):Focus on the strategic word, priority. Focus on the data in the question and note the relationship of the words undergoing induction and the correct option. Also recall that physiological needs are prioritized over psychosocial needs.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1.Infection 2.Hemorrhage 3.Chronic hypertension 4.Disseminated intravascular coagulation

2.Hemorrhage Rationale:In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa. Test-Taking Strategy(ies):Focus on the subject, the risks associated with placenta previa. Thinking about the pathophysiology associated with this disorder and recalling that bleeding is a primary concern in this client will direct you easily to the correct option.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? 1.Age 35 years 2.History of syphilis 3.History of genital herpes 4.History of diabetes mellitus

2.History of syphilis Rationale:Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion, although the presence of active lesions at the time of birth presents concerns. Maternal age greater than 40 years and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations, not abortions. Test-Taking Strategy(ies):Focus on the subject, risk factors associated with spontaneous abortion. Reading each choice carefully and focusing on the subject will assist in directing you to the correct option.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1.Providing comfort measures 2.Monitoring the fetal heart rate 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor

2.Monitoring the fetal heart rate Rationale:Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority. Test-Taking Strategy(ies):Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory and the ABCs—airway, breathing, and circulation—to assist in answering the question. These strategies will direct you to the correct option.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? 1.Prepare the client for an ultrasound. 2.Obtain equipment for a manual pelvic examination. 3.Prepare to draw a hemoglobin and hematocrit blood sample. 4.Obtain equipment for external electronic fetal heart rate monitoring.

2.Obtain equipment for a manual pelvic examination. Rationale:Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia. Test-Taking Strategy(ies):Focus on the subject, nursing care of the client with placenta previa. Use knowledge of the pathophysiology associated with placenta previa. Note the words question which prescription in the event query. Also, note that the correct option is the only procedure that is invasive to the pregnancy and endangers the physiological safety of the client and the fetus.

The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply. 1.A tender and rigid uterus 2.Painless, bright red vaginal bleeding 3.Location in the lower uterine segment 4.Greenish discoloration of the amniotic fluid 5.Vaginal bleeding accompanied by abdominal pain

2.Painless, bright red vaginal bleeding 3.Location in the lower uterine segment Rationale:Placenta previa is a condition in which the placenta is located in the lower uterine segment. It does not cause pain but does cause bright red vaginal bleeding. This occurs because the placenta is overriding the cervical os, and as the cervix dilates the placental vessels bleed. Abruptio placenta is painful and results in a rigid and tender uterus. Greenish discoloration of the amniotic fluid occurs as a result of meconium staining. Test-Taking Strategy(ies):Eliminate options 1 and 5 because they are comparable or alike. Recalling that placenta previa is a condition in which the placenta is covering the cervical os will assist you in eliminating option 4. Remember that there is no pain with placenta previa.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1.Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the primary health care provider (PHCP) stat. 4.Call the delivery room to notify the staff that the client will be transported immediately.

2.Place the client in Trendelenburg's position. Rationale:When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the PHCP and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation. Test-Taking Strategy(ies):Note the strategic word, initial, and the words umbilical cord protruding from the vagina. Options 3 and 4 can be eliminated first because these actions delay necessary and immediate treatment. Knowledge that the cord should not be pushed back into the vagina will easily direct you to the correct option.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1.Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the primary health care provider stat. 4.Call the delivery room to notify the staff that the client will be transported immediately.

2.Place the client in Trendelenburg's position. Rationale:When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation. Test-Taking Strategy(ies):Note the strategic word, first, and that the umbilical cord is protruding from the vagina. Options 3 and 4 can be eliminated first because these actions delay necessary and immediate treatment. Recalling that the goal is to relieve cord compression and to increase fetal oxygenation will direct you to the correct option. Also remember that the cord should not be pushed back into the vagina.

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1.Encourage the mother to breast-feed soon after birth. 2.Support the mother in her reaction to the newborn infant. 3.Tell the mother that it is important to hold the newborn infant. 4.Document a complete account of the mother's reaction on the birth record.

2.Support the mother in her reaction to the newborn infant. Rationale:Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings. Test-Taking Strategy(ies):Use therapeutic communication techniques. The correct option is the only option that acknowledges the client's feelings.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1.The client is a 35-year-old primigravida. 2.The client has a history of cardiac disease. 3.The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4.The client is a 20-year-old primigravida of average weight and height.

2.The client has a history of cardiac disease. Rationale: Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years. Test-Taking Strategy(ies):Options 1, 3, and 4 are comparable or alike and are average and normal findings. Also note that the correct option is the only option that identifies an abnormal condition.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1.Soft abdomen 2.Uterine tenderness 3.Absence of abdominal pain 4.Painless, bright red vaginal bleeding

2.Uterine tenderness Rationale:Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa. Test-Taking Strategy(ies):Focus on the subject, assessment findings in abruptio placentae. Remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bleeding with placenta previa.

The nurse is caring for a client in labor when a prolapsed umbilical cord is noted. In order of priority, which actions should the nurse take? All options must be used. 1.Prepare for immediate birth. 2. Monitor fetal heart rate and tones. 3.Elevate the fetal presenting part that is lying on the cord by applying gloved finger pressure. 4.Administer oxygen 8 to 10 L/min via 5.Place the client in Trendelenburg or knee-chest position.

3, 5, 4, 2, 1 Rationale:If umbilical cord prolapse occurs, the cord is lying alongside or below the presenting part of the fetus and can be seen or felt in or protruding from the vagina. The nurse stays with the client and asks another nurse to call the primary health care provider immediately. The nurse must relieve cord pressure immediately so that the fetus receives adequate oxygenation. The nurse can relieve cord pressure by elevating the fetal presenting part that is lying on the cord; the nurse does this by quickly gloving the hand and inserting 2 fingers into the vagina to the cervix and exerting upward pressure on the presenting part. The nurse also relieves cord pressure by placing the client into an extreme Trendelenburg or modified Sims' position or a knee-chest position (a rolled towel is placed under the client's hip). The nurse administers oxygen, 8 to 10 L/min, by face mask to the client, monitors the fetal heart rate and fetal heart rate patterns, and assesses the fetus for hypoxia. The client is prepared for immediate birth (vaginal or cesarean). The nurse documents the event, actions taken, the client's response, and any additional pertinent information. The nurse never attempts to push the cord into the uterus. If the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel saturated with warm sterile normal saline. Test-Taking Strategy(ies):Focus on the strategic word, priority. It is necessary to know that a prolapsed umbilical cord is an emergency. Client and fetal safety must be considered to answer this question correctly. Recalling that the immediate course of action is to ensure oxygenation and perfusion will assist in answering correctly.

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction? 1. Increase daily calories to ensure weight gain. 2. Maintain a supine position during rest periods. 3. Restrict visitors who may have an active infection. 4. Avoid becoming concerned about placing stress on the heart.

3. Restrict visitors who may have an active infection. Rationale:The client should avoid exposure to infection and not allow persons with active infections to visit. Too much weight gain causes an increase in body requirements and increases stress on the heart. The client should rest on the left side to promote blood return. Stress causes increased heart workload, with the potential for adverse consequences. Test-Taking Strategy(ies):Focus on the subject, home care measures, and on the diagnosis identified in the question. Recall that an infection can increase the workload of the heart. This should easily direct you to the correct option.

A pregnant woman of 30 weeks' gestation is admitted to the maternity unit in preterm labor. The woman asks the nurse about the purpose of betamethasone, which has been prescribed by the primary health care provider (PHCP). The nurse should tell the client that the medication will promote which action? 1. Delay delivery. 2. Prevent membrane rupture. 3. Enhance fetal lung maturity. 4. Stop the premature uterine contractions.

3. Enhance fetal lung maturity. Rationale:Betamethasone, a steroidal anti-inflammatory, increases the surfactant level and promotes lung maturation, thereby reducing the risk of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks of gestation, and if adequate amounts of lung surfactant are not present, respiratory distress and death of the newborn infant could result. Delivery should be delayed for at least 48 hours after administration of betamethasone to allow time for the lungs to mature. The other options are incorrect. Test-Taking Strategy(ies):Eliminate options 1 and 4 first because they are comparable or alike and relate to halting labor. Knowledge of the purpose of betamethasone is necessary to choose between the remaining options.

A client in preterm labor is being started on intravenous magnesium sulfate to stop the contractions. Several hours later, when the nurse is performing an assessment, the following data are obtained: blood pressure, 110/66 mm Hg; pulse, 66 beats per minute; respirations, 10 breaths per minute; and deep tendon reflexes absent. What should the nurse do next? 1. Institute seizure precautions. 2. Prepare for a precipitous delivery. 3. Prepare to administer calcium gluconate as an antidote for magnesium toxicity. 4. Increase the rate of magnesium sulfate, as the desired outcome has not yet been achieved.

3. Prepare to administer calcium gluconate as an antidote for magnesium toxicity. Rationale:The antidote for magnesium sulfate is calcium gluconate. This medication should be available if the client experiences magnesium toxicity. The respiratory rate and absence of deep tendon reflexes indicate magnesium toxicity and not the need for an increase in the rate of the medication. The client is not exhibiting signs and symptoms of preeclampsia, which might necessitate seizure precautions. There are no data to indicate that this client is experiencing a precipitous labor. Test-Taking Strategy(ies):Note the data in the question and focus on the subject, expected findings with the use of magnesium sulfate in preterm labor. Note the strategic word, next. Eliminate seizure precautions and precipitous delivery first because there are no assessment data to support these conditions. Recognize that there is an excess, not a shortage, of magnesium in the maternal system. Remember that the antidote for magnesium sulfate toxicity is calcium gluconate.

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? 1.Placenta previa 2.Polyhydramnios 3.Abruptio placentae 4.Gestational hypertension

3.Abruptio placentae Rationale:Trauma increases the incidence of miscarriage, preterm labor, abruptio placentae, and stillbirth. Careful evaluation of mother and fetus after any incident of trauma is essential. Placenta previa indicates that a placenta is implanted in the lower uterine segment near or over the internal cervical os. Risk factors that may precipitate placenta previa are not related to a traumatic event. Polyhydramnios is a term for excessive amniotic fluid, which would develop over time and not be a result of trauma. Although a motor vehicle crash may increase a woman's blood pressure, she would not be a candidate for gestational hypertension only because of the traumatic event. Test-Taking Strategy(ies):Focus on the strategic word, priority, and the presenting characteristics of the client. Noting that the client sustained trauma and thinking about the pathophysiology associated with each item in the options will direct you to the correct choice.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1.Postpartum infection 2.Maternal attachment 3.Maternal overexertion 4.Postpartum newborn-mother bonding

3.Maternal overexertion Rationale:The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although infection, maternal attachment, and bonding are appropriate nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac compromise. Test-Taking Strategy(ies):Focus on the subject, postpartum complications of a client with cardiac disease. Note the strategic word, most. Eliminate options 2 and 4 because they are comparable or alike. The correct option is the only one that relates directly to the issue of cardiac stress and safety.

A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? 1.Prone 2.Supine 3.On the side 4.Reverse Trendelenburg's

3.On the side Rationale:If cord prolapse or compression is suspected, the client is immediately repositioned. Cord compression needs to be relieved to allow for adequate fetal oxygenation. The client may be turned to the side or the hips may be elevated to shift the fetal presenting part toward the diaphragm, thereby relieving cord compression. A hands-and-knees position may reduce compression on a cord that is entrapped behind the fetus. Prone, supine, and reverse Trendelenburg's positions will not shift the presenting part toward the diaphragm and could worsen the condition. Test-Taking Strategy(ies):Note the strategic word, immediately. Focus on the subject, the presence of the umbilical cord protruding from the vagina, and visualize each position in the options. Recalling that cord compression needs to be relieved immediately will assist you in identifying the position in which the client should be placed.

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1.Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. 3.Perform a vaginal examination every shift. 4.Administer an antibiotic per prescription and per agency protocol.

3.Perform a vaginal examination every shift. Rationale:Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic. Test-Taking Strategy(ies):Note the word question. This word indicates the activity that the nurse should not implement without clarification. Options 1, 2, and 4 are comparable or alike and are expected activities for the nurse to perform for a client with premature rupture of the membranes. Performing a vaginal examination every shift should not be done on a client with premature rupture of the membranes because of the risk of infection, so the nurse would question this prescription.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age Rationale:Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation, as the blood penetrates the myometrium and causes uterine irritability. Test-Taking Strategy(ies):First, eliminate options 1 and 2 because they are comparable or alike. Next, remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bright red bleeding with placenta previa.

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? 1.The client is 28 years of age. 2.This is the second pregnancy. 3.The client has a history of hypertension. 4.The client performs moderate exercise on a regular daily schedule.

3.The client has a history of hypertension. Rationale:Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors. Test-Taking Strategy(ies):Note the subject, the risk factors associated with abruptio placentae. Age of 28 years, a second pregnancy, and moderate exercise can be eliminated because they are not situations that would present a risk for this condition.

A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? 1.Place the woman in a high-Fowler's position. 2.Palpate and evaluate contractions while administering a tocolytic. 3.Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. 4.Start an intravenous (IV) line with fluids to be administered at a keep-vein-open (KVO) rate only.

3.Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. Rationale:When an umbilical cord is protruding, nursing actions are immediately directed at reducing cord compression and facilitating delivery of the fetus. The cord is wrapped loosely in a sterile towel saturated with warm normal saline to prevent it from drying out and becoming compressed. The client is placed in an extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression. A tocolytic is used for inadequate uterine relaxation. IV solutions are administered at a rate greater than a KVO rate. Test-Taking Strategy(ies):Focus on the subject, the umbilical cord protruding from the vagina. Recall that the nursing concern is cord compression and drying of the cord. Select the option that protects the cord.

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? 1. "It is best that I rest lying on my side to promote blood return to the heart." 2. "I need to avoid excessive weight gain to prevent increased demands on my heart." 3. "I need to try to avoid stressful situations because stress increases the workload on the heart." 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." Rationale:To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Resting should be done by lying on the side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased heart workload, and the client should be instructed to avoid stress. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Using principles related to the therapeutic management of cardiac disease in general will assist in directing you to the correct option.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy." 2. "I should lower my blood volume by limiting my fluids." 3. "I should maintain a low-calorie diet to prevent any weight gain." 4. "I should drink adequate fluids and increase my intake of high-fiber foods."

4. "I should drink adequate fluids and increase my intake of high-fiber foods." Rationale:Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium should be restricted as prescribed by the primary health care provider, because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients. Test-Taking Strategy(ies):Focus on the subject, the pregnant client with heart disease. Think about the physiology of the cardiac system, maternal and fetal needs, and the factors that increase the workload on the heart. This will direct you to the correct option.

A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? 1. "I will need to remain on bed rest for 2 weeks." 2. "I will need to take a full course of antibiotic treatment." 3. "I will need to take tocolytic medication to halt the labor process." 4. "I will need to prepare myself and my family for the loss of this pregnancy."

4."I will need to prepare myself and my family for the loss of this pregnancy." Rationale:The client is experiencing a spontaneous abortion (miscarriage), which cannot be prevented and will terminate her pregnancy. Bed rest will not reverse this process. Test-Taking Strategy(ies):Focus on the data in the question, the client's last menstrual period, cramps, moderate vaginal bleeding, and a dilated cervix. Eliminate options 1, 2, and 3 because they suggest that the situation can be halted or reversed. The remaining option is the correct one.

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? 1.Allow family members to name the infant. 2.Encourage the client to talk about the dead fetus. 3.Allow the client and the spouse to hold the infant. 4.Assess the client's and the spouse's perception of the event.

4.Assess the client's and the spouse's perception of the event. Rationale:The initial intervention in planning to meet the emotional needs of the client and her spouse is to assess their perception of the event. Although the actions in the remaining options are likely to be components of the plan of care, the initial intervention in planning is to assess the perception of the event. Test-Taking Strategy(ies):Note the strategic word, initial. Use the steps of the nursing process to assist you in answering the question. Remember that assessment is the first step in the nursing process. The correct option addresses assessment whereas the incorrect options address implementation.

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement, the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? 1.A full bladder 2.Emotional instability 3.Insufficient iron intake 4.Compression of the vena cava

4.Compression of the vena cava Rationale:Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the left buttock during fundal height measurement will prevent or correct the problem. The remaining options are unrelated to this syndrome. Test-Taking Strategy(ies):Focus on the subject, the cause of lightheadedness during pregnancy. Noting the word physiological in the question will assist in eliminating option 2, emotional instability. Next, focus on the client's complaint. Recalling that compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome will direct you to the correct option.

The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 1.Administer oxygen to the woman. 2.Transport the woman to the delivery room. .Place an external fetal monitor on the woman. 4.Exert upward pressure against the presenting part.

4.Exert upward pressure against the presenting part. Rationale:If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place. Test-Taking Strategy(ies):Note the strategic word, immediately, and focus on the subject, that the umbilical cord is protruding from the vagina. Use the ABCs-airway, breathing, and circulation-and note that option 4 is the only choice that directly relates to the data in the question.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? 1.Back pain 2.Abdominal pain 3.Painful vaginal bleeding 4.Painless vaginal bleeding

4.Painless vaginal bleeding Rationale:The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of abruptio placentae. Test-Taking Strategy(ies):Focus on the subject, manifestations of placenta previa. Note that option 3 and the correct option oppose each other, which can be an indication that one of them may be correct. Recall that in placenta previa the client experiences painless vaginal bleeding.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3.Progressive changes in the cervix 4.Persistent nonreassuring fetal heart rate

4.Persistent nonreassuring fetal heart rate Rationale:Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor. Test-Taking Strategy(ies):Focus on the subject, signs of fetal or maternal compromise. Eliminate options 1, 2, and 3 because they are comparable or alike and are normal expectations during labor.

A client experiencing preterm labor at the 29th week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone but delivers too quickly for medication administration. As a result of not receiving this medication, which condition is most likely to develop in the preterm newborn? 1.Chlamydia 2.Hypoglycemia 3.Hyperbilirubinemia 4.Respiratory depression

4.Respiratory depression Rationale:Betamethasone is classified as an anti-inflammatory and corticosteroid. It increases the surfactant level and lung maturity in the fetus, which reduces the incidence of respiratory distress syndrome. Delivery must be delayed for at least 48 hours after administration of betamethasone to allow time for the lungs of the fetus to mature. Betamethasone is not related to treatment for Chlamydia, hypoglycemia, or hyperbilirubinemia. Test-Taking Strategy(ies):Note the strategic words, most likely, and focus on the subject, the purpose of administering betamethasone. Note the words 29th week of gestation. Specific knowledge of the medication and the problems encountered by preterm infants will assist you in answering this question.