Chapter 14 Prep-U (harder questions)

The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time? A. Administer oxygen. B. Have the woman change her position. C. Notify the health care provider. D. Continue to monitor the pattern every 15 minutes.

B R:Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the woman to change position to see if that will take the pressure off the cord. The health care provider should be notified, especially if a change of position is ineffective. The nurse should continue to monitor the pattern continuously until the situation is changed and to evaluate the effectiveness of interventions. This could be an ominous sign indicating the need for further interventions to include cesaeran delivery.

The nurse is performing Leopold's maneuvers as part of the initial assessment. Which action would the nurse do first? A. Feel for the fetal buttocks or head while palpating the abdomen. B. Palpate for the presenting part in the area just above the symphysis pubis. C. Determine flexion by pressing downward toward the symphysis pubis. D. Feel for the fetal back and limbs as the hands move laterally on the abdomen.

A R:The first maneuver involves feeling for the buttocks and head at the uterine fundus. Next the nurse palpates on which side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

A nurse is reviewing the FHR and notes it to be in the range of 100 to 106 bpm over the past 10 minutes. Which conditions might the nurse suspect as the cause? Select all that apply. A. prematurity B. prolonged umbilical cord compression C. fetal hypoxia D. maternal fever E. effect of maternal analgesia

B,C,E R:Fetal bradycardia occurs when the FHR is below 110 bpm and lasts 10 minutes or longer (Maso, Piccoli, De Seta, et al., 2015). It can be the initial response of a healthy fetus to asphyxia. Causes of fetal bradycardia might include fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block. Maternal fever and prematurity are associated causes of fetal tachycardia.

A patient in labor who is dilated 7 cm reports that narcotic pain medication given 3 hours ago has worn off and is asking for another dose. How should the nurse respond to this request? A. "Since it has been over 3 hours, you should be able to have more of the medication." B. "I will get permission from your doctor." C. "Your stage of labor makes giving another dose unsafe." D. "It is too early as the medication should be given only every 4 hours."

C R: The timing of administration of narcotics in labor is especially important. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth. The nurse does not need to get permission from the physician. Pain medication can be provided when needed and not on a set schedule of every 4 hours. The patient is nearing delivery so 3 hours from the last dose will not influence the decision to provide more medication.

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Continue to massage clients fundus R: The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.

The client reports having a rupture of membranes that occurred 24 hours ago. When assessing the client, which data is most pertinent? Select all that apply. A. I am having contractions which are 5 minutes apart. B. Your temperature is 38.3°C (101°F). C. Is your support person notified that you are here? D. The fetal monitor states that the fetal heart rate is 186 beats/min C. When was your last tetanus immunization? E. I am having green-tinged fluid discharge.

A,B,D,E R: The most pertinent data relates to the current client and fetal symptoms. A temperature of 38.3°C (101°F) is elevated. Green-tinged fluid possibly is meconium-stained amniotic fluid, indicating fetal distress. Contractions 5 minutes apart indicate the progression of labor. The fetal heart rate is elevated. Tetanus immunization is not a consideration at this time. Social considerations are not the most pertinent information to report.

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication? A. maternal hypotension B. uterine atony C. pruritus D. inadequate pain block

B R:A complication of general anesthesia is the relaxation of the uterine muscles, leading to uterine atony and possible postpartum hemorrhage. Maternal hypotension, a failed block, and pruritus are side effects of epidural analgesia.

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation? A. Short acting B. Regional C. Local D. General

D R:General anesthesia is reserved for emergencies in which the fetus must be delivered immediately to save the life of the fetus, mother or both. Regional anesthesia provides pain relief during labor and birth. Local anesthesia is typically a short-acting anesthesia used to numb the perineum.

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer? A. At the level of the umbilicus B. Midline but low on the abdomen C. On the right side of the abdomen D. On the uterine fundus

D R:The nurse is correct to place the tocodynamometer on the fundus with the sensor facing downward and then strap it securely to the abdomen. The other positions will relay information as well.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? A. Notify the health care provider. B. Prepare the client for birth. C. Perform Leopold's maneuver. D. Assess the client's cervical status.

A R: The nitrazine tape shows a pH between 5 and 6, which indicates an acidic environment with the presence of vaginal fluid and less blood. If the membranes had ruptured, amniotic fluid was present, or there was excess blood, the nitrazine test tape would have indicated an alkaline environment. The nurse would notify the healthcare provider for further assessment of the client.

The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize? A. Assess use of drugs, alcohol, and tobacco during pregnancy. B. Obtain a comprehensive obstetric history. C. Take blood pressure and determine if clonus or edema are present. D. Determine plans for labor and the newborn.

C R: In advanced labor, the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first, which would include the assessment of her blood pressure and presence of clonus or edema. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being? A. An increase in fetal movements B. The fetus descends further into the birth canal. C. Fetal heart rate acceleration occurs. D. Fetal heart rate deceleration occurs.

C R:The fetus is stimulated via an acoustic vibrator. From the stimulation, the fetal heart rate accelerates. If the acceleration occurs, fetal acidosis is not present. Fetal movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal.

The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? A. Use the Valsalva maneuver for effective pushing. B. Stay low on her back to ease the back pain. C. Use a birthing ball and find a position of comfort. D. Ask for privacy, and have just the partner present.

C R:The position is very important during labor. Allowing the woman to assume the most comfortable position will facilitate natural birth. The birthing ball allows the woman to move and adjust her position so that she can remain comfortable. The Valsalva maneuver may result in dangerous increases in blood pressure, so the nurse should be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. A. Determining the weight of the fetus B. Determining the size of the fetus C. Determining the lie of the fetus D. Determining the presentation of the fetus E. determining the position of the fetus

C,D,E R: Leopold maneuvers help the nurse to determine the presentation, position, and lie of the fetus. The approximate weight and size of the fetus can be determined with ultrasound sonography or abdominal palpation.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? A. maternal hypertension and fetal bradycardia B. maternal hypertension and fetal tachycardia C. maternal hypotension and fetal tachycardia D. maternal hypotension and fetal bradycardia

D R: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

A woman's perception of pain can differ according to all of the following except: A. the length of her labor. B. psychosocial, physiologic, and cultural influences. C. her expectations and preparation for labor. D. the presentation, lie, and attitude of the fetus. E. fear, anxiety, and self-efficacy.

D R: Fetal position can influence a client's perception of pain. Fetal attitude does not influence a client's perception of pain.

A client is ready to push. The nurse instructs her to push vigorously and grunt and breathe out during a pushing effort. What would be important to monitor on the client while she is pushing vigorously? A. temperature B. level of consciousness C. blood pressure D. fatigue

D R: Recent research has revealed that vigorous pushing techniques that employ the Valsalva maneuver are associated with increased fatigue. LOC is not normally affected and it is normally impractical to monitor blood pressure while the client is pushing vigorously.

The nurse is caring for a laboring client who has been administered a regional block for pain management. What is the nurse's priority action? A. Monitor the client closely for nausea and vomiting B. Encourage the client to adopt a side-lying position whenever possible C. Assess the client's pain at least once every 20 minutes D. Ensure that emergency equipment is readily available

D R:Emergency equipment must be kept at hand when a client receives regional anesthesia. A side-lying position is unnecessary and nausea is not a common adverse effect. Pain assessment should be more frequent than every 20 minutes.

Immediately following an epidural block, a pregnant patient's blood pressure suddenly falls to 90/50 mmHg. What action should the nurse take first?

Turn pt. onto the left side or raise the legs R: To help prevent supine hypotension syndrome, place the pregnant patient on the left side after an epidural block. If hypotension should occur, the patient's legs should be raised in addition to providing oxygen, intravenous fluids, and medication. The supine position encourages hypotension syndrome. Raising the head of the bed and deep breathing are not interventions to help with hypotension syndrome.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize? A. Maternal heart rate B. Blood pressure C. Respiratory status D. Level of consciousness

C R: Opioids like fentanyl have significant effects on the client's respiratory status. This is priority assessment because the other parameters are affected to a lesser degree.

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate adminstering?

zidovudine

Which nursing suggestions are options for the client experiencing intense pain in the active phase of labor? Select all that apply. A. Hypnosis B. Massage C. Effleurage D. Patterned breathing E. Acupressure F. Pain medication

A,B,D,E,F R:Depending upon the client's labor plan and the preparation she and her partner have received prior to the labor experience, patterned breathing, hypnosis, pain medication, massage and acupressure are all options to improve relaxation and pain management. Effleurage is also a technique used in pain management; however, it is only used in the early phase of labor.

The nurse is discussing the various positions for delivery with a client and her partner. The client mentions she would like a position which speeds up the process, decreases stress to her baby, and reduces the possibility of needing an episiotomy. Which positions should the nurse point out will best meet the client's desires? A. Hands and knees B. Side-lying C. Modified dorsal recumbent D. Lithotomy

A R: The hands and knees position is documented to be one of the best delivery positions for easing delivery and improving outcomes. Lithotomy (feet in stirrups), modified dorsal recumbent (feet on foot pedals), and side-lying are all potential positions, but not statistically the best. They also do not meet all the goals of the client.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. It would be most appropriate to meet which criterion? A. insertion by any staff B. the presenting fetal part not visible C. rupture of membranes D. cervical dilation of 1 cm

C R: The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

The health care provider and nurse are assisting the client in the delivery of the fetus. The mother has been pushing with little effect. As the nurse obtains the instruments to assist with delivery, which method is used for pain relief? A. A pudendal block B. IV pain medication C. General anesthesia D. An epidural

A R: A pudendal block is given just before the baby is born to provide pain relief for birth. Given at this time, the pudendal block does not impact the client's ability to push (which can prolong the labor). This block is also effective for births that require instruments to deliver the baby or complete an episiotomy. Though IV pain medication is rapid acting, it is not the analgesia of choice at this time. General anesthesia is used in emergency situations when the baby has to be delivered quickly. An epidural is for pain relief through the labor process.

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action? A. "I feel burning in my perineum." B. "My mouth and lips are so dry." C. "My lips and fingers are tingling." D. "My contractions are really intense now."

C R: When the client reports that her lips and fingers are tinging, the nurse is correct to understand that she is hyperventilating. To correct hyperventilation, the nurse instructs the client to slow the breathing. A paper bag or cupped hands is the correct nursing action. All of the other statements are normal for the client in the transition phase of labor. The nurse would moisten the client's lips or provide a lip balm for dry mouth or lips.

A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending?

Palpate the area just above the symphysis pubis. R: Palpate to determine if the infant is engaged and what the presenting part of the infant is by the symphysis pubis; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.

The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. What is the best response when the client's partner asks if she is getting sick? A. "The fever may be due to the epidural." B. "She may be developing an infection." C. "Have you been exposed to any illnesses recently?" D. "She's dehydrated and needs something to drink."

A R:A common side effect of epidural anesthesia is elevated temperature during labor. The client needs frequent assessment and to be observed for any other signs or symptoms of an infection, but it is premature to state it is related to an infection. If the mother has been exposed to any illness, it would be in the history. Oral fluids would not be advisable as they may result in nausea later.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. A. Assess client for underlying causes. B. Turn the client on her left side. C. Ignore questions from the client. D. Administer oxygen by mask. E. Reduce intravenous (IV) fluid rate.

A,B, D R:The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. A. intensity of contractions B. change in temperature C. uterine resting tone D. frequency of contractions E. change in blood pressure

A,C,D R: The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.

The physician of a patient in labor decides that an emergency cesarean birth is required to safely deliver the fetus. When preparing the operating room suite for this procedure, which medications should the nurse ensure are available for possible use? Select all that apply. A. Acetaminophen B. Ephedrine C. Atropine sulfate D. Diazepam E. Lactated ringer's solution

B,C,D R:To ensure safe general anesthesia administration, specific drugs must be readily available, which include diazepam to control seizures, ephedrine to use if the blood pressure falls, and atropine sulfate to dry secretions and prevent aspiration. Acetaminophen and lactated Ringer's solution are not specifically identified for use using general anesthesia.

A nurse is meeting with a client to develop the nursing care plan for her delivery to include the use of an injectable pain medication. When comparing the various options for the client, which advantage of using an intrathecal anesthesia over an epidural anesthesia should the nurse point out? A. Intrathecal anesthesia will not cause hypotension like epidural anesthesia can. B. Ambulation is still possible after an intrathecal anesthetic but not after receiving an epidural anesthetic. C. Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia. D. Epidural anesthesia has a tendency to wear off faster than intrathecal anesthesia.

C R:Onset of intrathecal (spinal) anesthesia is immediate. Epidural anesthesia can take 15 to 30 minutes to provide pain relief. Epidural anesthesia can be given in a continuous dosage; spinal anesthesia is given as a one-time injection that can wear off before delivery which would require some form of additional pain medication. Both epidural anesthesia and spinal anesthesia can cause hypotension. Both can be modified to effect mobility allowing the woman to be able to ambulate.

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? A. increased crying B. increased agitation C. decreased alertness D. low Apgars

C R: Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring? A. The client who has had a previous cesarean section B. The client who is having an uncomplicated labor C. The client who is very restless and is moving around in the bed D. The client who is having back labor and desires to lay on her side

C R:The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.