Chapter 11 & 12 Review Questions

Four Stages of Piaget's Theory of Cognitive Development

The Sensorimotor Stage The Preoperational Stage The Concrete Operational Stage The Formal Operational Stage

During an emergency birth the fetal head is crowning on the perineum. How should a nurse support the head as it is being born?

Distribute the fingers evenly around the head

At 40 weeks gestation a client is admitted to the birthing unit in early labor. She asks the nurse, "Why do you want me to lie on my side? What response explains the primary purpose of the side-lying position during labor?

"It enhances blood flow to the uterus and contractions"

A client in labor at 39 weeks gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth?

Active genital herpes

In the second stage of labor, the nurse should plan to discourage a client from holding her breath longer than 7 seconds while pushing with each contraction. What complication does this prevent?

Fetal hyposia

A pregnant woman at 39 weeks gestation arrives in the triage area of the birthing unit stating she thinks her "water broke." What should the nurse do first?

Check the vaginal introitus for the presence of the umbilical cord

The Preoperational Stage

Children begin to think symbolically and learn to use words and pictures to represent objects. Children at this stage tend to be egocentric and struggle to see things from the perspective of others. While they are getting better with language and thinking, they still tend to think about things in very concrete terms.

A client arrives at the clinic in preterm labor and terbutaline is prescribed. For what therapeutic effect should the nurse monitor the client?

Decreased frequency and duration of contractions

A client has been receiving oxytocin to augment labor. For what adverse reaction caused by a prolonged oxytocin infusion should the nurse monitor client?

Water intoxication

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious during this period and asks a nurse, "Do you think it is best for me to leave, because I don't seem to be doing my wife much good?" What is the nurse's best response?

"This is hard for you. Let me try to help you coach her during this difficult phase"

The Concrete Operational Stage

During this stage, children begin to thinking logically about concrete events They begin to understand the concept of conservation; that the amount of liquid in a short, wide cup is equal to that in a tall, skinny glass, for example Their thinking becomes more logical and organized, but still very concrete Children begin using inductive logic, or reasoning from specific information to a general principle

A client is admitted to the birthing unit in active labor. Cervical dilation has progressed from 2 to 3 cm during an 8-hour period. The health care provider determines that she has hypotonic dystocia, and infusion of oxytocin is prescribed to augment her contractions. What is the most important nursing action at this time?

Monitoring the duration and the intensity of the contractions

A client who is at 26 weeks gestation tells nurse at the prenatal clinic that she has pain when urinating, back tenderness, and pink-tinged urine. A diagnosis of pyelonephritis is made . What is the most important nursing intervention at this time?

Observing for signs of preterm labor

A pregnant client with severe abdominal pain and heavy bleeding is prepared for a cesarean birth. What is the priority nursing intervention?

Obtaining an informed consent and assessing for drug allergies

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?

Push with her glottis open

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What description of amniotic fluid supports this conclusion?

Straw colored, clear, and contains little white specks

A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveals the cervix at 3 cm dilation and 75% effacement, +1 station with occiput anterior, and intact membranes. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. Based on observations of the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond?

"It's all right for you to walk as long as you feel comfortable and your membranes are intact

After a client gives birth, what physiological occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

Appearance of a sudden gush of blood

During a client's labor, the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's first intervention?

Assist the client to turn to the side-lying position

The Formal Operational Stage

At this stage, the adolescent or young adult begins to think abstractly and reason about hypothetical problems Abstract thought emerges Teens begin to think more about moral, philosophical, ethical, social, and political issues that require theoretical and abstract reasoning Begin to use deductive logic, or reasoning from a general principle to specific information

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. How should the nurse respond?

Have her pant-blow during contractions

The membranes of client who is at 39 weeks gestation have ruptured spontaneously. Examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaed and the FHR is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival?

Introduce the staff nurses to the couple and try to make them feel welcome

A nurse performs Leopold maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in public area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify?

Left occipitoanterior (LOA)

An expectant couple asks the nurse about the cause of low pain in labor the nurse replies that this pain occurs most often when the position of the fetus is what?

Occiput posterior

A client at 38 weeks gestation is admitted for induction of labor. Her membranes ruptured 12 hours ago. There are no other signs of labor. Which medication does the nurse anticipate will be prescribed?

Oxytocin

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What should the nurse tell the client to do?

Pant while resisting the urge to bear down

A client asks the nurse at the prenatal clinic whether she can continue to have sexual relations while pregnant. What is an indication that the client should refrain from intercourse during pregnancy?

Premature rupture of membranes

A primigravida is concerned about the health of her baby and asks the nurse, " What is the most common cause of death of babies?" The nurse explains that the cause of more than half of the neonatal deaths in the United States is due to what?

Preterm births

A client is admitted to the birthing unit in active labor. An amniotomy is performed. What physiologic change does the nurse expect to occur after the procedure?

Progressive dilation and effacement

Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse identifies that the fetus is experiencing late declarations. Listing the following nursing actions in order of priority.

Reposition client on her side Increase IV fluids Reassess fetal heart rate pattern If late decelerations persist, notify the health care provider Document interventions with related maternal/fetal responses

A client is receiving an IV piggyback infusion of oxytocin to augment labor. The nurse identifies that there have been three contractions lasting 80 to 90 seconds that are less than 2 minutes apart. There is a specific protocol that is followed in response to this observation. List in order of priority the nursing actions that should be taken.

Stop the piggyback infusion Check the fetal heart rate Determine whether the contractions have diminished Notify the health care provider Administer oxygen via face mask Document maternal/fetal reponse

Despite medication, a client's preterm labor continues her cervix dilates, and birth appears to be inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival?

Terbutaline

A primipara gave birth to an infant weighing 9 pounds 15 ounces (4508 g). She had a midline episiotomy and a third-degree laceration. She tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain?

The anal sphincter muscle has been injured

The Sensorimotor Stage

The infant knows the world through their movements and sensations Children learn about the world through basic actions such as sucking, grasping, looking, and listening Infants learn that things continue to exist even though they cannot be seen (object permanence) They are separate beings from the people and objects around them They realize that their actions can cause things to happen in the world around them

When a client's legs are placed in stirrups for birth, the nurse confirms that both legs are positioned simultaneously to prevent what?

Trauma to the uterine ligaments

What is the safest position for a woman in labor when a nurse observes a prolapsed cord?

Trendelenburg

Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor?

Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia