Unit 3 (20 21 22)

A client pregnant with twins asks if the pregnancy will be uncomplicated. How should the nurse respond to this client?

1. "The perinatal mortality rate for monoamniotic siblings is 50%." 2. "Twins are less likely to have complications than are singleton births." 3. "Spontaneously conceived twins are less likely to develop complications." 4. "Primiparous women pregnant with twins are less likely to develop complications." Answer: 3 This is true. Spontaneously conceived twins are less likely to develop complications Page 418

For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. What should the nurse include when explaining the location of the episiotomy to the client?

1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4. "Through your rectal sphincter." Answer: 4 A third-degree laceration includes the rectal sphincter. Page Ref: 439

The clinical nurse coordinator is reviewing the care of clients who undergo artificial rupture of membranes (AROM) by way of amniotomy with a group of nursing students. Which student statement indicates that the teaching has been effective?

1. "Amniotomy is contraindicated for use in labor augmentation." 2. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." 3. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'" 4. "In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed." Answer: 2 Following .AROM, because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal examinations must be kept to a minimum to reduce the chance of introducing an infection. Page 450

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which participant statement indicates that additional information is needed?

1. "Because my hospital is so small and in a rural area, they will not let me attempt a VBAC." 2. "Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 3. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." 4. "My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down." Answer: 2 Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classic vertical incisions on the uterus have a higher rate of rupture and should not be attempted. Page 465

A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed?

1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collar bone broken." Answer: 1 Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus Page 435

The client is instructing a client recovering from a classic uterine incision for a cesarean birth. Which statement indicates that the client understands implications for future pregnancies that are secondary to this type of incision?

1. "I can only have one more baby." 2. "The next time I have a baby, I can try to deliver vaginally." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "The risk of rupturing my uterus is too high for me to have any more babies." Answer: 3 A classic uterine incision is made in the upper uterine segment and holds an increased risk of rupture in subsequent pregnancy, labor, and birth. Page 462

The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement indicates that further information is required?

1. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 2. "Soaking in the tub will help my mediolateral episiotomy to heal." 3. "The tear I have through my rectum is unrelated to my episiotomy." 4. "Because I have a midline episiotomy, I should keep my perineum clean." Answer: 3 This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum. Page 457

A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. How should the nurse respond to this request?

1. "I will get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I will bring you an extra so that you can change it when you are ready." Answer: 3 Optimal effects from the use of an ice pack occur when it is applied for 20 to 30 minutes and then removed for at least 20 minutes before being reapplied. Page 458

A pregnant client is diagnosed with cervical insufficiency. How should the nurse expect this client to explain symptoms of this condition?

1. "I've been having contractions every 4 hours." 2. "I'm not having any pain and I do not feel any contractions." 3. "My cervical pain has gotten much worse over the past 2 days." 4. "I'm not having any pain, but my contractions are getting stronger." Answer: 2 Cervical insufficiency is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix. Page 416

The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching?

1. "If I have bleeding in the third trimester of my next pregnancy, I might rupture membranes again." 2. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 3. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 4. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." Answer: 2 There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM. Page 406

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention?

1. "Multipara, transverse lie." 2. "Primipara failed ECV last week." 3. "Primipara, frank breech ballotable." 4. "Multipara, 32 weeks, complete breech." Answer: 4 ECV is not attempted until 36 weeks. This client is too early in her pregnancy for ECV. Page Ref: 449

The clinical instructor reviews postoperative care of cerclage with a group of nursing students. Which student statement indicates the need for further information?

1. "Sometimes cerclage can be performed on an outclient basis." 2. "If cerclage is performed emergently, the client will usually be hospitalized for at least 5 days." 3. "After 37 weeks' gestation, the client's cerclage may be cut in order to allow for vaginal delivery." 4. "If the client's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed." Answer: 4 Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure. Page Ref: 417

A client experiencing a difficult labor is going to have vacuum extraction to facilitate delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance?

1. "The baby's head might have a bruise from the vacuum cup." 2. "The vacuum will be applied for a total of 10 minutes or less." 3. "I can stop pushing and just rest if the vacuum extractor is used." 4. "A small cup will be put onto the baby's head, and a gentle suction will be applied." Answer: 3 Vacuum extraction is an assistive delivery, and the client must continue with pushing efforts to accomplish the birth. Page 460

A client at 38 weeks' gestation is diagnosed with oligohydramnios. Which statement indicates that teaching has been effective?

1. "When I go into labor, I should come to the hospital right away." 2. "My gestational diabetes may have caused this problem to develop." 3. "Women with this condition usually go into labor after their due date." 4. "This problem is common and will likely occur with my next pregnancy." Answer: 1 The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the client with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop. Page 421

The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern?

1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4. 30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz Answer: 1 Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern. Page 426

The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first?

1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push 2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 4. 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously Answer: 3 Bleeding with a placenta previa is a complication that can be life threatening to both the mother and baby. This client is the highest priority. Page 411

A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate?

1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4. Oxytocin administration Answer: 2 Cesarean section is the most likely course of action. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed. Page 439

A multigravida client with suspected abruptio placentae is admitted in active labor. Which nursing diagnoses should the nurse identify as appropriate for this client? Select all that apply.

1. Anxiety related to concern for own safety 2. Ineffective Coping related to premature birth 3. Fluid Volume, Risk for Deficit, related to hypovolemia 4. Tissue Perfusion, Risk for Altered, related to blood loss 5. Knowledge Deficit related to lack of information about inherited genetic defects Answer: 1, 3, 4 1. Abruptio placentae can cause anxiety for both the client and fetus. 3. Maternal mortality and perinatal fetal mortality are concerns due to blood loss. 4. Maternal mortality and perinatal fetal mortality are concerns due to hypoxia. Page 415

A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important?

1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4. Monitor maternal blood pressure every 15 minutes. Answer: 3 This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture. Page 434

The home health nurse is visiting the home of a client who is 18 weeks pregnant with twins. Which nursing action is most important?

1. Assess the client's blood pressure in the upper right arm. 2. Collect a cervicovaginal fetal fibronectin (fFN) specimen. 3. Teach the client about foods that are good sources of protein. 4. Determine whether the pregnancy is a result of infertility treatment. Answer: 3 A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth. Page 419

A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client?

1. Assessing blood pressure every 2 hours 2. Evaluating the fetal heart rate with an internal monitor 3. Limiting vaginal examinations to only one per 24-hour period 4. Monitoring for blood loss, pain, and uterine contractibility Answer: 4 Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety. Page Ref: 411

A primiparous client is at 42 weeks' gestation. What order should the nurse question?

1. Begin non-stress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4. Schedule labor induction for tomorrow. Answer: 2 A postterm pregnancy is high risk. Fetal assessments must be obtained to verify fetal well-being or the need for delivery via induction or cesarean. One week is too long a time period between assessments. Page 427

The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention?

1. Bladder is emptied using a straight catheter. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. Regional anesthesia is administered via pudendal block. Answer: 2 The client should only push during contractions, not between contractions. Page 459

A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority?

1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV of lactated Ringer solution. 4. Apply antiembolism stockings. Answer: 3 The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary. Page 439

A pregnant client is scheduled for a transabdominal cerclage. What teaching information should the nurse prepare for this client? Select all that apply.

1. Cesarean section birth 2. Preoperative laparotomy 3. Potential for hydramnios 4. Risk for abruptio placentae 5. Premature rupture of membranes Answer: 1, 2 1. Transabdominal cerclage placement typically results in a cesarean section birth. 2. Transabdominal cerclage placement requires a laparotomy for placement and removal. Page 411

A client at 40 weeks' gestation is prescribed dinoprostone (Cervidil) for cervical ripening. What should the nurse include when teaching the client about this medication? Select all that apply.

1. Cramping can occur. 2. Uterine irritability is expected. 3. Membrane rupture is a sign of labor. 4. Leakage of the gel should be reported. 5. Strong regular contractions are expected. Answer: 1, 2, 3 1. Cramping is a common reaction to the medication. 2. Uterine irritability is a common reaction to the medication. 3. Membrane rupture is a sign of labor and not a reaction to the medication. Page 451

The nurse is reviewing the medical history of a pregnant client being considered for cervical ripening. Which data indicate that the order for misoprostol (Cytotec) should be reconsidered? Select all that apply.

1. Current fetal heart rate is tachycardic. 2. Client had one cesarean live birth 3 years ago. 3. Uterine contractions are occurring every 2 minutes. 4. Client has 2+ pedal edema and elevated blood pressure. 5. There is a history of placenta previa with one previous pregnancy. Answer: 1, 2, 3 1. Absolute contraindications for the use of misoprostol include fetal tachycardia. 2. Absolute contraindications for the use of misoprostol include a history of previous cesarean birth. 3. Absolute contraindications for the use of misoprostol include the presence of uterine contractions 3 times in 10 minutes. Page 451

A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time?

1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4. Assist the client to squat during the second stage. Answer: 4 Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk. Page Ref: 439

A client at 39 weeks' gestation being prepared for labor induction feels as though the baby has "flipped." What action should the nurse take?

1. Evaluate fetal maturity. 2. Administer dinoprostone (Cervidil) vaginal gel. 3. Implement continuous electronic fetal monitoring (EFM). 4. Notify the healthcare provider that the client feels as though the baby has changed position. Answer: 4 Because malpresentation, such as breech, is a relative contraindication to induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. Page Ref: 452

The nurse is caring for the newborn of a client who received magnesium sulfate for preterm labor. Which fetal effects should the nurse attribute to the client's medication treatment? Select all that apply.

1. Flushing 2. Lethargy 3. Hypotonia 4. Poor sucking reflex 5. Respiratory depression Answer: 2, 3, 5 2. Fetal side effects of magnesium sulfate may include lethargy that persists for 1 or 2 days following birth. 3. Fetal side effects of magnesium sulfate may include hypotonia that persists for 1 or 2 days following birth. 5. Respiratory depression in the newborn can also occur after maternal magnesium sulfate. Page Ref: 408

When caring for a client with oligohydramnios, on what should the nurse focus? Select all that apply.

1. Induction is typically scheduled. 2. Early decelerations are more likely. 3. Fetal pulmonary hypoplasia can develop. 4. There is an increased risk of cord compression. 5. Labor progress is often more rapid than average. Answer: 1, 2, 3, 4 1. As soon as the fetus is term, induction is typically scheduled because the fetus is at an increased risk for intrauterine fetal demise. 2. Decreased amniotic fluid can contribute to fetal head compression, which can manifest itself as early decelerations. 3. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. 4. Less amniotic fluid lessens the cushioning effect, and cord compression is more likely. Page Ref: 421

After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing?

1. Infection 2. Placenta accreta 3. Hypertensive crisis 4. Amniotic fluid embolus Answer: 4 Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death. Page Ref: 438

The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention?

1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway." Answer: 4 Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority. Page Ref: 437

The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. What risk factors should the nurse include about this health problem? Select all that apply.

1. Multiparity 2. Preterm labor 3. Diabetes mellitus 4. Abruptio placentae 5. Prolonged retention of a fetus after demise Answer: 4, 5 4. Abruptio placentae leaves intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. 5. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC. Page Ref: 414

A pregnant client receiving oxytocin for labor induction begins demonstrating adverse effects of the medication. In which order should the nurse provide care to this client?

1. Notify the healthcare provider. 2. Discontinue the oxytocin infusion. 3. Position the client onto the left side. 4. Infuse prescribed intravenous fluids. 5. Administer oxygen 8 to 10 L per tight face mask. Answer: 2, 4, 3, 5, 1 1. After applying oxygen the healthcare provider should be notified. 2. Nursing management of adverse effects begins by discontinuing the IV oxytocin infusion. 3. After intravenous fluids are started, the client should be turned onto the side. 4. After the oxytocin infusion is discontinued, the primary intravenous solution should be opened up for immediate infusion. 5. After positioning on the side, oxygen by tight face mask at 8 to 10 L/min should be administered. Page Ref: 453

The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important?

1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour. Answer: 2 Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow. Page 436

The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time?

1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid. Answer: 2 Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated Page 437

A client at 40 weeks' gestation is being considered for cervical ripening. Which criteria should the nurse use to determine the client's success for induction? Select all that apply.

1. Position 2. Effacement 3. Consistency 4. Fetal heart rate 5. Cervical dilatation Answer: 1, 2, 3, 5 1. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include position. 2. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include effacement. 3. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include consistency. 5. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include cervical dilatation. Page Ref: 451

A client is recovering from general anesthesia after an emergency cesarean birth. What actions should the nurse take when providing care to this client? Select all that apply.

1. Position on the left side. 2. Observe urine for hematuria. 3. Assess level of anesthesia every 15 minutes. 4. Evaluate perineal pad every 15 minutes for 1 hour. 5. Gently palpate the fundus with vital signs assessment . Answer: 1, 2, 4, 5 1. If the client has been under general anesthesia, she should be positioned on her side to facilitate drainage of secretions. 2. It is important to observe the urine for a bloody tinge, which could mean surgical trauma to the bladder.. 4. After a cesarean section, evaluate the dressing and perineal pad every 15 minutes for at least 1 hour. 5. The fundus should be gently palpated to determine whether it is remaining firm. Page Ref: 465

What should the nurse anticipate the labor pattern for a fetal occiput posterior position to be?

1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4. Prolonged with regard to the overall length of labor Answer: 4 The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor. Page Ref: 429

A client in the midst of labor and delivery of twins is being considered for a podalic version. What should the nurse assess in order for this version to be considered? Select all that apply.

1. Previous cesarean birth 2. Second fetus does not descend 3. Premature rupture of membranes 4. Presence of third-trimester bleeding 5. Second fetus heart rate nonreassuring Answer: 2, 5 2. A podalic version is used only with the second fetus during a vaginal twin birth and only if the twin does not descend readily. 5. A podalic version is used only with the second fetus during a vaginal twin birth and only if the heart rate is nonreassuring. Page Ref: 449

A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor?

1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4. Occiput anterior (OA) fetal position Answer: 3 The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed. Page 438

The risk management nurse is reviewing labor and delivery statistics over the last 2 years in an effort to decrease costs of maternity care. What finding contributes to increased healthcare costs in clients undergoing cesarean birth by request?

1. Prolonged anemia, requiring blood transfusions every few months 2. Increased abnormal placenta implantation in subsequent pregnancies 3. Decreased use of general anesthesia with greater use of epidural anesthesia 4. Coordination of career projects of both partners leading to increased income Answer: 2 Placenta implantation problems are more common after cesarean birth and increase healthcare costs because of the high-risk care and testing required. Page 461

The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply.

1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations Answer: 1, 2, 5 1. The presence of prolonged decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 2. The presence of persistent late decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 5. The presence of persistent and severe variable decelerations is a sign of monreassuring fetal status. Intrauterine resuscitation should be started without delay. Page Ref: 436

The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply.

1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby. Answer: 2, 3, 4 2. The fetus should be bathed/cleansed and wrapped in a blanket in preparation for viewing. 3. The client should be asked her preference for viewing and holding the baby. 4. It is inappropriate for the nurse to instruct the client on home care needed after delivery at this time. The client and family are having a highly emotional experience which should not be ignored. Page 444

A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. What action should the nurse make a priority at this time?

1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD). Answer: 4 The client is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions. Page Ref: 426

The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4. Family refusing fetal autopsy Answer: 2 Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level and indicates that the client is in DIC. Page 441

For which reason should the nurse suspect hydramnios in a pregnant client?

1. The client is pregnant with twins. 2. The quadruple screen comes back positive. 3. There is less amniotic fluid than normal for gestation. 4. The fundal height increases disproportionately to the gestation. Answer: 4 The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation. Page Ref: 420

A pregnant client diagnosed with hydramnios asks for more information about this health problem. What should the nurse include in this teaching? Select all that apply.

1. The exact cause is unknown. 2. It can cause shortness of breath and edema. 3. It can be associated with maternal diabetes. 4. It occurs in large-for-gestational-age infants. 5. It is associated with renal malformation or dysfunction. Answer: 1, 2, 3 1. The exact cause of hydramnios is unknown. 2. Hydramnios can cause maternal shortness of breath and edema. 3. Hydramnios is associated with maternal diabetes. Page 420

A client experiencing a difficult labor has a vacuum extraction birth. What is expected with this type of delivery?

1. The head is delivered after eight pulls during contractions. 2. The location of the vacuum is apparent on the fetal scalp after birth. 3. A bruise is present on the occiput that does not cross the suture line. 4. Positive pressure is applied by the vacuum extraction during contractions. Answer: 2 Caput in the shape of the vacuum cup is usually present immediately after birth and resolves in 2 to 3 days. Page 460

A pregnant client is diagnosed with central abruptio placentae. What can the nurse infer about the client's condition?

1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding. 2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage. 3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding. 4. Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding. Answer: 3 With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding. Page 413

The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. What is the last assessment that the nurse should make before the client is draped for surgery?

1. Vaginal examination 2. Fetal heart tones 3. Maternal temperature 4. Maternal urine output Answer: 2 Fetal heart tones are assessed just prior to the start of surgery because the supine position can lead to fetal hypoxia. Page 464