Success Guide Exam #3
What is a blottable head?
Moves away from touch
The physician has ordered dinoprostone for four gravidas at term. The nurse should question the order for who?
Multigravida with late decelerations
A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into?
Fetal position
The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her POC?
Muscle relaxation Pelvic rocking ABD massage
Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia?
Assess fetal heart rate Infuse 1L of LR Have the woman empty her bladder
The client at 39 weeks gestation, FHR baseline at 144 BPM tells the admitting nurse that the has had to wear a pad for the last four days because of leaking fluid. What is the appropriate action?
Assess the fluid with nitrazine
A low risk, 38 weeks gestation woman calls the L&D unit and says that she saw pink on the toilet tissue and is bleeding. Which of the following responses should the nurse make first?
"You seem frightened"
One hour ago, a multipara was examined with the following results: 8cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introits. The nurse concludes that the client is now:
10cm dilated, 100% effaced, & 5+ station
The nurse is assessing an internal fetal heart monitor tracing of an uneducated, full-term gravid who is in transition. Which of the following heart rate patterns would the nurse interpret as normal?
Baseline of 140-150 BPM with decelerations to 100 BPM that mirror each of the contractions
Ideal MVU?
250 MVU over 10M of strip
A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time?
2cm
Soft round mass
Buttocks
What are caffeine restrictions for pregnant women?
300mg/day
What is the caloric requirement in 2nd & 3rd trimesters of pregnancy?
340-426 calories per day increase
What is adequate pressure of a contraction?
50+ mmHg
When can you change augmenting agents in labor?
After 4H
When during the latent phase of labor should the nurse assess the fetal heart pattern of a low risk patient, G1 P0000
After vaginal examination Before administration of analgesics Periodically at the end of a contraction Before ambulating
What can a lack of folic acid create?
Anencephale and spina bifida
Carboprost (Hemabate)
Can produce bronchial spasm in individuals with asthma
The nurse wishes to assess the variability of the FHR. Which of the following actions must the nurse perform at this time?
Carefully analyze the baseline data on the monitor tracing
Cephalohematoma
Collection of blood underneath the skin (does not cross the suture lines)
A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions is appropriate at this time?
Continue to provide encouragement during each contraction
A client, G4 P1021, has been admitted to the L&D suite for induction of labor. The assessments are as followed: Bishop score of 2 FHR of 156 BPM with good variability and no decelerations TPR 98.6 F P: 88 BPM RR: 20 BPM BP: 120/80 Negative OB history Dinoprostone has been inserted Which finding would warrant removal of the prostaglandins?
Contraction frequency of 1M
A nurse describes a client's contraction pattern as: frequency of every 3M and duration of 60S. Which of the following correlates to the description?
Contraction lasting one minute followed by a 120 second rest period
What defines tachysystole?
Contractions less than 2 minutes apart
When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 BPM from a baseline of 120 BPM. One occurred during a contraction and the other 10 seconds after. A third occurred 40 seconds after another contraction. What is this interpreted as?
Cord compression
What is your first priority after AROM?
Fetal heart tones
A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.
Delivery of a healthy baby
What are the cardinal movements of labor in order?
Descent Internal rotation Extension External rotation Expulsion
On exam of a full term primipara, a labor nurse notes: active labor, ROA, 7cm dilated, & 3+ station. Which of the following should the nurse report to the physician?
Descent is progressing well
The nurse documents in a laboring woman's chart the the FHR is begin assessed via intermittent auscultation. To be consistent with this statement, the nurse, using a Doppler electrode, should assess the FHR at which of the following times?
For 1 minute immediately following contractions
The nurse turns off the oxytocin infusion after a period of tachysystole. What outcome indicates that the action was effective?
Frequency of every 3M
A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula?
Give the woman a back rub Assist the woman with her breathing
What HR requires chest compressions of the newborn?
HR < 60 BPM
Small objects
Hands & feet
The nurse knows that which of the following responses is the primary rationale for the inclusion of the info taught in childbirth education classes?
Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle
When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place the fetoscope to heart the fetal heartbeat?
LLQ
A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. RScT (right scapular transverse). 4. ROP (right occiput posterior).
LMA
The L&D nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings?
LOA
During a vaginal exam, the nurse palpates fetal buttocks that are facing the left posterior and are 1cm above the ischial spine. Which of the following is consistent with this assessment?
LSP -1
A physician has notified the suite that four clients will be admitted to the unit. Which client would be a candidate for external version?
LSP position
Where does GBS come from?
Lack of stomach acidity & overgrowth in the GI tract (possible poor nutritional support)
How close to contractions need to be for cervical change?
Less than 5M apart
What are risk factors for postpartum hemorrhage?
Low lying placenta, large baby
In response to a patient's request, the nurse asks the PCP for meds to relieve labor pain. The provider ordered self administered inhaled nitrous oxide. What are the common side effects the nurse should monitor the mother for?
Nausea Light-headedness
Sinciput or military stance
Neutral neck
The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions?
OP
O
Occiput
Flexion
Occiput bone is presenting
What nutrients encourage neurogenesis?
Omega 3s
The nurse is providing acupressure for pain relief to a woman in labor. Where is the best location for the pressure to be applied?
On the medial aspect of the lower leg On the top 1/3 of the sole of the foot
A OB is performing an amniotomy on a woman in transition. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the electrode?
RUQ
If a patient is having increased pain on one side after an epidural, what should the nurse do?
Reposition to the affected side and give a med bolus
The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravid is appropriate at this time?
Risk for impaired skin integrity
S
Sacrum
A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be question if the fetal presenting part is which of the following?
Scapula
SC
Scapula
Which of the following situations should the nurse conclude is a vaginal delivery emergency?
Shoulder dystocia
A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing techniques for the latent phase of labor. Which of the following techniques did the nurse teach?
Slow chest breathing
After an epidural, the client is sitting up at 30 degrees. She claims that she feels like she is going to pass out and throw up...what is happening?
Spinal headache
A client in labor, G2 P1001, was admitted one hour ago at 2cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation?
The client is exhibiting an expected behavior for labor
While evaluating FHR monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time?
The relationship between the decelerations and the labor contractions
During the third stage of labor, the following physiological changes occur in what pattern?
The uterus contracts The uterine surface area dramatically decreases Hematoma forms behind the placenta Membranes separate from the uterine wall
A woman had a baby by normal spontaneous delivery 10 minutes ago. The nursenotes that a gush of blood was just expelled from the vagina and the umbilical cordlengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods
The woman is about to deliver the placenta
A pregnant woman is discussing possible delivery options with a labor nurse. Which of the following client responses indicates that the woman understood the information?
When the client states, "I am glad that deliveries can take place in a variety of places, including the labor bed" When the client states, "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees" When the client says, "During difficult deliveries it is sometimes necessary to put a woman's legs up in stirrups" When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting positions"
Four women request to labor in the hospital bathtub. Which of the women is at increased risk from the procedure? 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with meconium stained fluid.
Woman receiving oxytocin for induction and meconium stained fluid
It is 4P. A client, G1 P0000, 3cm dilated, asks the nurse when the dinner tray will be served. The nurse replies...
"A heavy meal is discouraged. I can get clear fluids for you whenever you would like them though"
A client telephones the suite and states that her water just broke and it smells funny. What is the appropriate response?
"Have you felt the baby kick since the membranes broke?"
A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear?
"I can't stand this pain any longer"
A gravid client at term calls the labor suite at 7P questioning whether she was in labor. The nurse determined that the client was likely in labor after she said:
"I took a shower about a half hour ago. The contractions hurt more than they did before.
How many doses of PCN are preferable?
2
How much liquid should the antepartum client consume?
2-3L
Clients are being augmented with oxytocin. Which woman should be monitored carefully for potential of uterine rupture?
Age 25, G4 P3003, last delivery by C-section
What is the best position for labor?
Any anterior
Flat object
Back
A client just SROMed. Which factors increase the risk for a prolapsed cord?
Breech presentation Station -3 Transverse lie
A nurses is caring for a laboring woman who is in transition. Which of the following S/S would indicate that the woman is progressing into the second stage of labor?
Bulging perineum Increased bloody show Uncontrollable urge to push
Misoprostol
Cervical ripening and postpartum hemorrhage
A nurse is monitoring the labor of a client who is receiving IV oxytocin at 6 mL/hour. What sign would lead the nurse to stop the infusion?
Change in FHR from 128 to 102 BPM
Why should you combine citrus and iron?
Citrus increases iron absorption
A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse take at this time?
Cover the woman's perineum with a sheet
A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following info about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment?
Weight gain Ethnicity & religion Age Gravidity and parity
A woman is in active labor and is being monitored electronically. She has just received Stadol 2mg IM for pain. Which of the following fetal heart responses would the nurse expect to see?
Decreased variability
On vaginal exam, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline FHR is 130 with no decelerations. Which of the following nursing actions is appropriate at this time.
Delay pushing until the baby descends farther and the mother has a strong urge to push
A 40 week gestation woman has received miso-rostov for cervical ripening. What S/S should the nurse carefully monitor for?
Diarrhea and back pain
The nurse is assessing a client who states that she thinks she is in labor. Which of the following findings would positively confirm the client's belief?
Dilated from 2-4cm
A client just received IV Stadol for pain relief. What should the nurse anticipate?
Diminished short and long term variability
A client is complaining of severe back labor. Which of the following nursing interventions would be most effective?
Direct sacral pressure
What is a engaged head?
Doesn't move with touch
Methergine
Elevates blood pressure
Hard round mass
Head
Asynclitic
Head positioned down and toward one shoulder
What does the breech presentation put the fetus at risk for?
Hip displasia
What types of food cause listeriosis?
Hot dogs Deli meats Soft cheeses (bleu, brie, feta)
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of distress. Which action should the nurse take?
Increase the IV infusion rate
The nurse auscultates FHR of 152 BPM on a client in early labor. Which of the following actions by the nurse is appropriate?
Inform the mother that the rate is normal
Which action is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor?
Inquire regarding the woman's pain level
What vitamins do antacids impact?
Iron and calcium
The nurse is assessing the fetal station during a vaginal exam. Which of the following structures should the nurse palpate?
Ischial spine
M
Mentum or chin
Caput
Molding and crossing of the suture lines of the skull
The childbirth education nurse is evaluating the learning of four women, 38-40 weeks gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements?
Pain in the back & lower ABD every 5 minutes Gush of clear fluid from the vagina Greenish discharge from the vagina
A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetalhead is of average dimensions.
The anterior to posterior diameter of the pelvis will accommodate a fetus with an average sized head
The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."
The baby is almost crowning
Immediately following the administration of an epidural anesthesia, the nurse must monitor the mother for which side effect?
Drop in blood pressure
A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time?
Encourage the woman to grunt during contractions
A woman, G2 P0101, 5cm dilated, 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulders and face muscles are beginning to tense during contractions. Which of the following interventions should the nurse perform first?
Encourage the woman to perform the next level breathing
Immediately after a woman SROMs, the nurse notices a loop of umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform?
Place the client in knee-to-chest position
PURE
Position Urine Relaxation Environment
Vertex
Presenting part is the occiput
A G1 P0, 8cm dilated, is to receive pain medication. The PCP has decided to order an opiate analgesic with a med that reduces some of the side effects of the medication. Which of the following medications would the nurse expect to be ordered in conjunction with the analgesic?
Phenergan (promethazine)
A client, G2 P1001, 5cm dilated and 40% effaced, has just received an epidural. Which action is important for the nurse to take at this time?
Place a wedge under the woman's side
Why is folic acid important?
Encourages replication of cells as they are without breaks (if the cell is abnormal, it will replicate abnormally)
A woman is to receive dinoprostone gel for labor induction. The nurse should be prepared to administer the medication via which route?
Endo-cervically
Which non-pharmacological interventions recommended by nurse midwives may help a client at full term go into labor?
Engage in sexual intercourse Ingest evening primrose oil Massage the breasts and nipples
Why is folate important?
Ensures the perfect replication when the neural tube folds over (creating the brain and spinal cord)
A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first?
Evaluate the process of labor
During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor?
Extension
The practitioner is performing a fetal scalp stimulation test. Which fetal response would the nurse expect to see?
Fetal heart acceleration
A woman has just arrived at the labor and delivery suite. To report the client's status to her PCP, which of the following assessments should the nurse perform?
Fetal heart rate Contraction pattern Vital signs
A nurse is assessing vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect?
HTN
A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? 1. Fetal heart assessment after each contraction. 2. Uterus rising in the abdomen and feeling globular. 3. Rapid cervical dilation to ten centimeters. 4. Maternal complaints of intense rectal pressure. 5. Lengthening of the umbilical cord
Lengthening umbilical cord Uterus rising in the abdomen and feeling globular
To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery?
Massage the perineum with mineral oil
A client is admitted in labor with SROM 24H earlier. The fluid is clear and FHR is 124 BPM with moderate variability. What assessment is most important at this time?
Maternal temperature
A primigravida client received dinoprostone for induction 8H ago. The Bishop score is now 10. What action by the nurse is appropriate?
Monitor for onset of labor
Upon exam, a nurse notes that a woman is 10cm dilated, 100% effaced, and 3- station. Which of the following signs should the nurse perform during the next contraction?
Monitor for signs of rectal pressure
A woman, G3 P1010, is receiving oxytocin via IV pump at 3 milliunits/minute. Her current contraction pattern is every 3M X 45S with moderate intensity. The FHR is 150-160 BPM with moderate variability. Which of the following interventions should the nurse take at this time?
Monitor the client's labor
In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions?
Performing effleurage
A woman is scheduled to have an external version for a breech presentation. The nurse carefully reviews the client's chart for contraindications to this procedure, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Station -2 2. 38 weeks' gestation 3. Abnormal fetal heart rate and tracing 4. Previous cesarean section 5. Rupture of membranes
Previous C-section Left sacral post
A woman is scheduled to have an external version for a breech presentation. The nurse carefully reviews the client's chart for contraindications to this procedure, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Station -2 2. 38 weeks' gestation 3. Abnormal fetal heart rate and tracing 4. Previous cesarean section 5. Rupture of membranes
Previous C-sectionLeft sacral post
While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 BPM. What should the nurse do?
Provide caring labor support
Where should oxytocin be placed in relation to another line?
Proximal to the site
The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the woman learn?
Push down with an open glottis
A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.
Take a slow breath before bearing down
A multipara, LOA, station 3+, who has had no pain medication during her labor is now in stage two of labor. She states that her pain is 6/10 and that she wants an epidural. Which of the following responses is appropriate?
The baby is going to be born soon. It really is too late for an epidural.
A woman, who is in active labor is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest
The baby's chin is resting on it's chest
A woman, 40 weeks gestation calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements indicates that she is probably in labor?
The contractions are about one minute long and I am unable to talk through them
An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.
The fetal head has entered the true pelvis
While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse?
The fetal lie is vertical
After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to these findings?
The fetus has a healthy nervous system
A woman, G1 P0000, 40 weeks gestation, entered the labor suite stating that she is in labor. Upon exam, it is noted that the woman is 2cm dilated, 30% effaced, contracting every 12M for 30S, FHR is in the 140ish BPM with good variability and spontaneous accelerations. Which should the nurse conclude when reporting the findings to the PCP?
The woman is in early labor and can be sent home
A nurse concludes that a woman is in the latent phase of labor. Which of the following S/S would lead to that conclusion?
The woman is talking and laughing during contractions
Why aren't babies born with vitamin K?
They don't have bacteria in their gut and vitamin K and B12 need bacteria to be extracted from food sources and stored
The nurse is performing a vaginal exam on a client in labor. The client is found to be 5cm dilated, 90% effaced, and -2 station. Which of the following has the nurse palpated?
Thin cervix
What other assessments should be documented after AROM?
Time of rupture Amount of fluid Fluid characteristics
The physician orders oxytocin for induction for 4 gravidas. Which situation should the nurse refuse to comply with this order?
Transverse lie
When should the nurse refuse to provide forceps for delivery?
Transverse lie position Mentum presentation and 1- station
A client, 38 weeks gestation is being induced with oxytocin for HTN and oligohydraminos. She is contracting Q3M X 60-90S. She suddenly complains of ABD pain accompanied by significant fetal bradycardia. What intervention should be performed first?
Turn off the oxytocin infusion
A nurse is teaching childbirth education to a group of pregnant teens. Which of the following strategies would promote learning by the young women?
Utilizing visual aids like movies and posters during the class
A full-term client, contracting every 15 min x 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1.Intermittent fetal heart auscultation. 2.Vaginal examination. 3.Intravenous fluid administration. 4.Nipple stimulation
Vaginal examination
A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable info regarding the client's labor status?
Vaginal examination
The nurse is interpreting the results of a fetal blood sampling test. Which report would the nurse expect to see?
pH of 7.30