Chapter 26&27 Quiz
A pregnant patient comes into the clinic complaining of constipation. Which statement by the patient indicates the need for further teaching? "I need to drink 8 to 10 glasses of water a day." "I can stop taking my vitamins if I have hemorrhoids." "I am walking around the block every day." "I need to increase the amount of fiber in my diet."
"I can stop taking my vitamins if I have hemorrhoids."
A pregnant patient asks the nurse about a darkened line that is seen on her abdomen. What would be the best response? "That is chloasma, the mask of pregnancy." "That is striae gravidarum, or more commonly known as stretch marks." "That is linea nigra, a darkened line from the pubis to the umbilicus, as a result of increased hormones." "That is spider nevi, a branched growth of dilated capillaries on the skin."
"That is linea nigra, a darkened line from the pubis to the umbilicus, as a result of increased hormones."
1. A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15
1. A. CORRECT: April 1st minus 3 months plus 7 days and 1 year equals an estimated date of delivery of January 8. B. This is incorrect using Nägele's rule. C. This is incorrect using Nägele's rule. D. This is incorrect using Nägele's rule. @ NCLEX® Connection: Health Promotion and Maintenance, Data Collection Techniques
1. A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A. "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne.' D. "A contraceptive patch is replaced once a month."
1. A. CORRECT: Condoms are used with water-soluble lubricants. B. A diaphragm should be removed no sooner than 6 hr and no later than 24 hr after intercourse. C. Acne is reduced when taking oral contraceptives. D. Contraceptive patches are replaced once a week. @ NCLEX® Connection: Health Promotion and Maintenance, Lifestyle Choices
1. A nurse in a prenatal clinic is reinforcing education to a client who is at 8 weeks of gestation. The client states, "I don't like milk." Which of the following foods should the nurse recommend as a good source of calcium? A. Dark green leafy vegetables B. Deep red or orange vegetables C. White breads and rice D. Meat, poultry, and fish
1. A. CORRECT: Good sources of calcium for bone and teeth formation include low-oxalate, dark green leafy vegetables (kale, artichokes, turnip greens). B. Deep red or orange vegetables are good sources of vitamins C and A. C. White breads and rice do not contain high levels of calcium. D. Meat, poultry, and fish are sources of protein but do not contain high levels of calcium. © NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration
1. A nurse is providing reinforcement to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (Select all that apply.) A. Avoid any lifting. B. Perform Kegel exercises twice a day. C. Perform the pelvic rock exercise every day. D. Use proper body mechanics. E. Avoid constrictive clothing.
1. A. Lifting can be done by using the legs rather than the back. B. Kegel exercises are done to strengthen the perineal muscles and do not relieve backache. C. CORRECT: The pelvic rock or tilt exercise stretches the muscles of the lower back and helps relieve lower-back pain. D. CORRECT: The use of proper body mechanics prevents back injury due to the incorrect use of muscles when lifting. E. Avoiding constrictive clothing helps prevent urinary tract infections, vaginal infections, varicosities, and edema of the lower extremities. © NCLEX® Connection: Basic Care and Comfort, Non-Pharmacological Comfort Interventions
A pregnant patient comes to the clinic for a prenatal visit. At how many weeks' gestation would the patient need to be to hear fetal heart tones using a Doppler scan? 4 weeks 10 weeks 16 weeks 18 weeks
10 weeks
While in the clinic, a first-time pregnant patient asks the nurse when she should be able to feel the fetus move. What is the nurse's best response? 14 to 16 weeks' gestation 10 to 12 weeks' gestation 8 to 10 weeks' gestation 6 to 8 weeks' gestation
14 to 16 weeks' gestation
2. A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 PO A1 L1. How should the nurse interpret this information? (Select all that apply.) A. Client has delivered one newborn at term. B. Client has experienced no preterm labor. C. Client has been through active labor. D. Client has had two prior pregnancies. E. Client has one living child.
2. A. CORRECT: T1 indicates the client has delivered one newborn at term. B. CORRECT: PO indicates the client has had no preterm deliveries. C. A1 indicates the client has had one miscarriage. D. CORRECT: G3 indicates the client has had two prior pregnancies and the client is currently pregnant. E. CORRECT: L1 indicates the client has one living child. © NCLEX® Connection: Health Promotion and Maintenance, Data Collection Techniques
2. A nurse is reinforcing teaching with a client who is pregnant about manifestations of complications to promptly report to the provider. Which of the following complications should the nurse reinforce to the client? A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Lightheadedness when lying on back
2. A. CORRECT: Vaginal bleeding indicates a potential complication of the placenta such as placenta previa. Instruct the client to notify the provider immediately. B. Swelling of the ankles is a common occurrence during pregnancy and can be relieved by sitting with the legs elevated. C. Heartburn occurs during pregnancy due to pressure on the stomach by the enlarging uterus. It can be relieved by eating small meals. D. Supine hypotension can be experienced by the client who feels lightheaded or faint when lying on their back. Instruct the client about the side-lying position to remove pressure of the uterus on the vena cava. © NCLEX® Connection: Reduction of Risk Potential, Potential for Alterations in Body Systems
2. A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite
2. A. Reduced menstrual flow is a common adverse effect of oral contraceptives and usually subsides after a few months of use. B. Breast tenderness is a common adverse effect of oral contraceptives and usually subsides after a few months of use. C. CORRECT: Shortness of breath can indicate a pulmonary embolus or myocardial infarction and should be reported to the provider immediately. D. Increased appetite is a common adverse effect of oral contraceptive and does not have to be reported to the provider. @ NCLEX® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions
2. A nurse in a prenatal clinic is assisting with caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? A. 1.8 kg (4 lb) weight gain and is in the first trimester B. 3.6 kg (8 lb) weight gain and is in the first trimester C. 6.8 kg (15 lb) weight gain and is in the second trimester D. 11.3 kg (25 lb) weight gain and is in the third trimester
2. A. This client has gained the appropriate weight of 3 to 4 lb for a client in the first trimester. B. CORRECT: The nurse should be concerned about this client because they have exceeded the expected 3- to 4-Ib weight gain of a client in the first trimester. C. This client has gained the appropriate weight of 3 to 4 lb. in the first trimester and approximately 1 lb per week in the second trimester. D. This client is within the recommended weight gain of 25 to 35 lb during the third trimester. © NCLEX® Connection: Health Promotion and Maintenance, Data Collection Techniques
A nurse is collecting data on a patient who is 28 weeks pregnant. What would the nurse expect the fundal height to measure in centimeters? 20 cm 28 cm 32 cm 36 cm
28 cm
3. A nurse in an obstetrical clinic is reinforcing teaching with a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam.' B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed." D. "I will check to be sure the strings of the IUD are still present after my periods."
3. A. An IUD will be replaced every 3 to 5 years, dependent upon the type of IUD used. B. Clients do not have to have given birth prior to the insertion of an IUD. It will be necessary for the client to have a negative pregnancy test prior to insertion of the IUD. C. Fertility will resume immediately following removal of the IUD. D. CORRECT: The client should check for presence of IUD strings following each menstruation to ensure the device is still present. A change in the length of the strings should be reported to the provider. @, NCLEX® Connection: Pharmacological and Therapies, Expected Actions/Outcomes
3. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include? A. Eat crackers or plain toast before getting out of bed. B. Awaken during the night to eat a snack. C. Skip breakfast and eat lunch after nausea has subsided. D. Eat a large evening meal.
3. A. CORRECT: Nausea and vomiting during the first trimester might be relieved by eating crackers or plain toast prior to rising in the morning. B. Eating during the night can cause heartburn and does not relieve nausea and vomiting during the first trimester. C. Instruct the client to avoid an empty stomach for prolonged periods to reduce nausea and vomiting. D. Eating a large meal in the evening can cause heartburn and does not relieve morning nausea and vomiting. © NCLEX® Connection: Reduction of Risk Potential, Potential for Alterations in Body Systems
3. A nurse in a clinic is reinforcing teaching with a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A. Iron deficiency anemia B. Poor bone formation C. Macrosomic fetus D. Neural tube defects
3. A. Iron deficiency anemia is the result of a lack of iron-rich dietary sources (meat, chicken, fish). B. Calcium deficiency can result in poor bone and teeth formation. C. Maternal obesity can lead to a macrosomic fetus. D CORRECT: Neural tube defects are caused by folic acid deficiency. Food sources of folic acid include fresh green leafy vegetables, liver, peanuts, cereals, and whole-grain breads. @ NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention
3. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (Select all that apply.) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening
3. A. Montgomery's glands are a presumptive sign of pregnancy. B. CORRECT: Goodell's sign is a probable sign of pregnancy. C. CORRECT: Ballottement is a probable sign of pregnancy. D. CORRECT: Chadwick's sign is a probable sign of pregnancy. E. Quickening is a presumptive sign of pregnancy. @ NCLEX® Connection: Health Promotion and Maintenance, Data Collection Techniques
4. A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava. D. "This is due to increased cardiac output."
4. A. An increase in blood volume during pregnancy results in cardiac hypertrophy. B. Pressure from the gravid uterus on the diaphragm might cause the client to experience shortness of breath. C. CORRECT: Maternal hypotension occurs when the client is lying in the supine position and the weight of the gravid uterus places pressure on the vena cava, decreasing venous blood flow to the heart. D. An increase in cardiac output during pregnancy results in cardiac hypertrophy. © NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
4. A nurse is providing reinforcement to a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (Select all that apply.) A. Breast tenderness B. Urinary frequency C. Epistaxis D. Dysuria E. Epigastric pain
4. A. CORRECT: Breast tenderness is a common discomfort occurring during the first trimester of pregnancy. B. CORRECT: Urinary frequency is a common discomfort occurring during the first trimester of pregnancy. C. CORRECT: Epistaxis is a common discomfort occurring during the first trimester of pregnancy. D. Dysuria is a complication that might occur during pregnancy. Instruct the client to report this finding to the provider. E. Epigastric pain is a clinical finding of pregnancy-induced hypertension. Instruct the client to report this finding to the provider © NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
4. A nurse is reinforcing teaching with a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Select all that apply.) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. Nausea E. Gingival hyperplasia
4. A. Tinnitus is not an adverse effect of implantable progestins. B. CORRECT: Irregular vaginal bleeding is a potential adverse effect of implantable progestins. C. CORRECT: Weight gain is a potential adverse effect of implantable progestins. D. CORRECT: Nausea is a potential adverse effect of implantable progestins. E. Gingival hyperplasia is not a potential adverse effect of implantable progestins. © NCLEX® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions
4. A nurse is reviewing a new prescription for iron supplements with a client who is at 8 weeks of gestation and has iron deficiency anemia. Which of the following beverages should the nurse reinforce the client to take the iron supplements with? A. Ice water B. Low-fat or whole milk C. Tea or coffee D. Orange juice
4. A. Water does not promote absorption of iron, but drinking plenty of water can prevent constipation, which is an adverse effect of iron supplements. B. Milk interferes with iron absorption. C. Caffeine, found in tea and coffee, can interfere with iron absorption. The client should consume no more than 200 mg/day because it increases the risk of spontaneous abortion or fetal intrauterine growth restriction. D. CORRECT: Orange juice contains vitamin C, which aids in the absorption of iron. © NCLEX® Connection: Pharmacological Therapies, Medication Administration
5. A nurse in a clinic is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Weight fluctuations can occur." B. "You are protected against STIs." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur."
5. A. CORRECT: Weight fluctuations can occur when taking medroxyprogesterone. B. Medroxyprogesterone does not provide protection against STIs. C. CORRECT: Clients should take calcium and vitamin D to prevent loss of bone density, which can occur when taking medroxyprogesterone. D. Antibiotics are not contraindicated when taking medroxyprogesterone. E. CORRECT: Medroxyprogesterone can cause irregular vaginal bleeding. © NCLEX® Connection: Pharmacological Therapies, Medication Administration
5. A nurse is assisting the charge nurse with reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? "I am glad I can have my morning coffee." B. "I should take folic acid to increase my milk supply." C. "I will continue adding 330 calories per day to my diet." D. "I will continue my calcium supplements because I don't like milk."
5. A. Clients who are breastfeeding should avoid caffeine intake because it affects iron absorption and infant weight gain. B. Folic acid does not increase milk production. C. Clients who are breastfeeding require an additional 450 to 500 calories per day to support adequate nutrition. D. CORRECT: Postpartum clients who are at risk for inadequate dietary calcium should continue taking calcium supplements during lactation. © NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration
5. A nurse in a clinic receives a phone call from a client who would like information about pregnancy testing. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested for pregnancy." B. "You should be off any medications for 24 hours prior to the pregnancy test." C. "You should not eat or drink for at least 8 hours prior to the pregnancy test." D. "You should use your first morning urination specimen for a home pregnancy test."
5. A. The production of hG can be detected as early as 7 to 8 days before expected menses. B. Do not advise the client to stop taking medications in preparation for pregnancy tests. Review the client's medications to determine whether they can affect the results. C. Do not advise the client to remain PO prior to pregnancy testing. Blood tests are not affected by food or fluid intake. D. CORRECT: Urine pregnancy tests should be done on a first-voided morning specimen to provide the most accurate results. D NCLEX® Connection: Reduction of Risk Potential, Laboratory Values
5. A client who is at 8 weeks of gestation tells the nurse, "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make? A. "I will inform the provider that you are having these feelings." B. "It is normal to have these feelings during the first few months of pregnancy." C. "You should be happy that you are going to bring new life into the world." D. "I am going to make an appointment with the counselor for you to discuss these thoughts."
5. A. This is a nontherapeutic response by the nurse and does not acknowledge the client's concerns. B. CORRECT: Feelings of ambivalence about pregnancy are normal during the first trimester. C. This is a nontherapeutic response by the nurse and indicates disapproval. D. This is a nontherapeutic response by the nurse and does not acknowledge the client's feelings. @ NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
The baby is assessed after birth and the follow ing are noted: heart rate 124 bpm; respiratory effort good, crying; some flexion of the extremities; grimacing; body pink, extremities bluish. Based on this information, what is the Apgar score? ____________
7 (see tbl 27.5)
Which of the following maternal changes are presumptive signs of pregnancy? (Select all that apply.) Amenorrhea Breast changes Hegar sign Chadwick sign Fetal heart tones
Amenorrhea Breast changes Chadwick sign
Which patients would be likely candidates for induction of labor? Select all that apply. 1. Patient had rupture of membranes 6 hours ago and labor has not started. 2. Patient has high blood pressure with symptoms of headache and dizziness. 3. Patient has a history of one stillbirth and one fetal demise. 4. Patient has diabetes mellitus. 5. Patient has documented placenta previa. 6. Patient has active herpes simplex infection.
Answer 1, 2, 3, 4: Hypertension, diabetes, and history of stillbirth or fetal demise are reasons for induction. In the case of ruptured membranes for 6 hours with no onset of spontaneous contractions, induction of labor would be recommended. Placenta previa and herpes simplex infection are contraindications for induction.
All members of the health care team have performed hand hygiene. Which members are appropriately using personal protective equipment while caring for the mother and infant during childbirth? Select all that apply. 1. Unlicensed assistive personnel (UAP) wears clean gloves when cleaning the perineal area after a bowel movement. 2. HCP wears a sterile waterproof gown and gloves, a mask with shield, cap, and shoe covers when delivering infant. 3. Nurse wears a gown and gloves when handling the newborn immediately after birth. 4. Nurse wears clean gloves and gown when inserting an internal scalp electrode. 5. Nurse wears sterile gloves when inserting a urinary catheter.
Answer 1, 2, 3, 5: An internal scalp electrode is considered invasive, so the nurse should use sterile gloves. The other members of the health care team are demonstrating correct use of personal protective equipment.
Which questions would be most important for the admission assessment of a patient in labor? Select all that apply. 1. "When did the contractions begin?" 2. "How far apart are the contractions?" 3. "Did you take your prenatal vitamin today?" 4. "Did your water break?" 5. "Do you plan to have the baby circumcised if it is a male?" 6. "Have you noted any vaginal bleeding?" 7. "How long do you plan to breastfeed your baby?"
Answer 1, 2, 4, 6: The most important data to collect from the patient upon admission is the information about what is happening with labor. The nurse would inquire as to the onset of labor and the frequency, duration, and intensity of the contractions. The nurse would need to know if the water has broken and if the patient is bleeding to get an idea of how the labor has progressed at this point. While the nurse would want to document the patient's medication and vitamin intake and her plans for circumcision and breastfeeding, these items would not take priority.
Which patients may be candidates for cesarean delivery? Select all that apply. 1. Cephalopelvic disproportion is present. 2. Mother is a nullipara. 3. Mother has a cardiac condition. 4. Prolapse of cord is present. 5. Presentation is breech. 6. Fetus has a heart rate of 140 bpm.
Answer 1, 3, 4, 5: Indications for cesarean birth can be maternal or fetal. The major maternal indications for cesarean delivery are cephalopelvic disproportion, previous cesarean delivery, breech presentation, medical conditions that would endanger the mother's health such as certain cardiac complications, abnormal conditions of the placenta such as placenta previa, infections of the vaginal canal, and pelvic abnormalities. Major fetal indicators are fetal oxygen deprivation, prolapse of the umbilical cord, breech presentation, malpresentations such as transverse lie, and congenital anomalies.
The nurse is comparing today's fundal height measurement with the previous recording taken 5 weeks ago. What is the significance of a stable or decreased measurement? 1. Possible intrauterine growth restriction 2. Possible multifetal gestation 3. Possible excessive amniotic fluid 4. Expected normal finding
Answer 1: A stable or decreased fundal height may indicate intrauterine growth restriction (IUGR); an excessive increase could indicate multifetal gestation or hydramnios (excessive amniotic fluid). It would not be normal to show no growth in 5 weeks, and further evaluation would be indicated.
Which factor increases the risk of transverse lie of the fetus? 1. A history of seven prior full-term pregnancies 2. A history of cesarean section. 3. Placenta implanted in the fundus of the uterus 4. The pregnant woman is underweight
Answer 1: A transverse lie would be more likely in a woman with a history of seven prior full-term pregnancies. These pregnancies would likely have weakened the woman's abdominal musculature, which reduces the muscular support that helps the fetus maintain the normal longitudinal lie. Sometimes, use of an elastic binder can be helpful with patients in late pregnancy to maintain a longitudinal lie. A prior cesarean section would not increase the risk. A placenta implanted in the fundus is normal and would not increase risk, nor would the underweight status of the woman.
The provider tells the patient at 39 weeks that it is likely that she is having a vaginal discharge called bloody show. What additional information would the nurse provide? 1. Explain that bloody show can be normal at 39 weeks gestation. 2. Advise the patient that she must go to the hospital immediately. 3. Prepare the patient for cesarean section. 4. Inform the patient that she is now at increased risk for infection.
Answer 1: Bloody show is a blood-tinged vaginal mucus that may be observed as normal at 39 weeks gestation and would suggest that labor may start soon. The patient would not need to go to the hospital, nor prepare for a cesarean birth. The presence of bloody show does not increase the patient's risk for infection.
The pregnant woman reports blurring and double vision. Which assessment would the nurse immediately perform? 1. Check the patient's blood pressure. 2. Assess the patient's visual acuity. 3. Auscultate the lungs and count respirations. 4. Assess balance and coordination.
Answer 1: Blurring and diplopia (double vision) can be associated with pre eclampsia. The nurse would check the blood pressure and then report the blood pressure and the symptoms immediately to the HCP.
About 2 weeks before the due date, a nullipara patient reports that the "lightening" that was described in the prenatal classes has occurred. Which physical change is likely to occur because of the lightening? 1. Urinary frequency 2. Decreased fetal movement 3. Shortness of breath 4. Leakage of amniotic fluid
Answer 1: Lightening refers to the descent of the fetus into the pelvis. This places more weight on the urinary bladder, so urinary frequency is expected. The space in the chest cavity opens up, so breathing should improve. Decreased fetal movement should not occur and leakage of amniotic fluid is not expected to accompany lightening.
For which patient would the nurse anticipate that the uterine contractions may temporarily become less frequent and intense? 1. Woman who received an epidural analgesia early in labor 2. Woman who has been paraplegic for past several years 3. Adolescent who is nullipara 4. Older woman who is multipara
Answer 1: Opioid analgesic medication or epidural analgesia early in labor may temporarily cause uterine contractions to become less frequent and intense. Paraplegia should not affect the intensity or frequency, because uterine contractions are involuntary. The parity of the woman would not be a major risk for the lessening of the contractions.
The nurse is examining the umbilical cord immediately after delivery. Which finding would be reported to the HCP for further investigation of fetal anomalies? 1. The cord has two vessels—one artery and one vein. 2. The cord contains a significant amount of Wharton's jelly. 3. The cord is 50 cm long and 2.5 cm in diameter. 4. The cord has a pale white, ropelike appearance.
Answer 1: Ordinarily, the cord would have three vessels: two arteries and one vein. One artery and one vein may be associated with fetal anomalies and requires follow-up. The other findings are expected.
Premature rupture of membranes increases the risk for which complication? 1. Infection for mother and fetus 2. Failure to progress 3. Uterine hemorrhage 4. Precipitous labor
Answer 1: Premature rupture of membranes increases the risk of infection for the mother and fetus, especially if labor is prolonged. It does not increase risk for the other listed complications.
The patient is receiving intravenous (IV) oxytocin for uterine inertia. The nurse notes that the fetal heart rate (FHR) is dropping below 100 bpm. What would the nurse do? 1. Stop the infusion. 2. Slow down the infusion. 3. Monitor the FHR for 5-10 full cycles of contractions. 4. Do nothing, as this is an expected response.
Answer 1: Stop the infusion and contact the provider if there are signs or symptoms of complications, such as changes in fetal heart rate; bradycardia; tachycardia; arrhythmias; or excessive frequency, duration, or pressure of contractions.
A new nurse is performing fundal massage. When would the supervising nurse intervene? 1. Explains to patient that rationale is to help placenta to deliver 2. Supports uterus from below with one hand 3. Uses upper hand to apply firm downward pressure 4. Observes perineum for number and size of clots
Answer 1: The purpose of the massage is to encourage the uterus to contract and expel blood and clots. It is done only after the delivery of the placenta. The other actions of the student nurse are correct.
Which topics would be included in a discussion about the birth plan? Select all that apply. 1. When to get pregnant 2. Labor 3. Delivery 4. Postpartum period 5. Fetal development 6. Genetic counseling
Answer 2, 3, 4: A birth plan addresses the patient's preferences for her care in labor, delivery, and the postpartum period. The plan would evolve out of patient discussion with her HCP, nurse, and childbirth instructor or doula. A birth plan needs to be flexible due to the variations in how labor and birth will unfold for each individual. Discussion of fetal development would occur during the first trimester of pregnancy. Discussion of when to get pregnant would occur during preconception counseling, and genetic counseling could be indicated both in the preconception period and in early pregnancy
What is an expected finding for a woman who is in the mid- to active phase of labor? 1. Cervical dilation of 2 cm 2. Contractions every 3-5 minutes 3. A desire to ambulate 4. Very mild, easily controlled pain
Answer 2: Contractions are expected every 3-5 minutes with 4- to 7-cm dilation. Pain will be manageable, but is intensified compared to earlier. Desire to walk is more likely in the latent phase.
The patient is at risk for a miscarriage. Which diagnostic test result is consistent with a miscarriage? 1. Elevated levels of maternal serum alpha-fetoprotein 2. Declining levels of quantitative human chorionic gonadotropin 3. Increasing levels of amniotic fluid 4. Positive findings for chorionic villus sampling
Answer 2: Declining levels of human chorionic gonadotropin suggest a miscarriage. Maternal serum alpha-fetoprotein is used to predict certain types of birth defects. A small sample of amniotic fluid could be tested for genetic factors such as sex and chromosomal abnormalities, health status, and maturity of the fetus. Chorionic villus sampling is used to detect genetic disorders.
When coaching the patient through the early or latent phase of labor, which breathing technique is the nurse most likely to encourage? 1. Shallow panting 2. Slow, deep chest or abdominal breathing 3. Acceleration through contractions 4. Holding the breath for 5 seconds and exhaling
Answer 2: Early, or latent, phase: slow, deep chest or abdominal breathing, 6-9 breaths/min; inhale through nose and out through pursed lips. Middle, or active, phase: Slow acceleration then deceleration of breaths through contraction; breaths shallow; approximately 16-20 breaths/min. Transitional phase: 4-6 pants followed by a blow for duration of contraction. Remind patient to take deep, cleansing breath before and after contraction to increase oxygen intake.
What is the first intervention that the nurse would perform in the care of an infant who has just been delivered? 1. Place the infant in contact with the mother's skin. 2. Assess airway and use a bulb syringe if indicated to clear mucus and fluid from infant's mouth and nose. 3. Place identification bracelets on both mother and infant. 4. Immediately dry the infant to help reduce heat loss from evaporation.
Answer 2: First, the airway should be assessed and cleared of excess fluid and mucus in the mouth and nose if needed. The other actions are also correct. If the newborn is stable, skin-to-skin contact with the mother is recommended and the infant can be kept warm while on the mother's chest or abdomen by placing a prewarmed blanket over the newborn.
The woman in labor has chosen to have epidural anesthesia. Which potential side effect would the nurse anticipate? 1. Postspinal headache 2. Hypotension 3. Aspiration 4. Respiratory depression
Answer 2: Hypotension is a common side effect after administration of epidural anesthesia. The nurse would monitor the blood pressure, report hypotension to the HCP, reposition the patient, and increase the IV rate if approved to do so by protocol. A postspinal headache may be seen after a saddle block or spinal anesthesia. It could also occur with epidural anesthesia if the dura were unexpectedly punctured but this would not be an expected side effect. Aspiration would be a risk with general anesthesia.
The pregnant woman is a heavy smoker and she feels that it is unlikely that she will be able to quit. Because of the oxygen deprivation in utero, which outcome would the health care team be prepared to deal with? 1. Neonatal jaundice 2. Preterm delivery with low birth weight 3. Intrauterine infection 4. No change in fetal heart rate during contraction
Answer 2: Maternal smoking is associated with preterm delivery, low birth weight, and decreased intrauterine growth. Neonatal jaundice and intrauterine infection are complications that are not associated with maternal smoking. No change in fetal heart rate during contractions is a sign of a healthy fetus; this is detected during the contraction stress test.
Which patient is most likely to undergo x-ray pelvimetry? 1. Patient is relatively thin and is in the early part of the first trimester. 2. Patient is not currently pregnant but has a history of pelvic fracture. 3. Patient is in the second trimester and multiple fetuses are suspected. 4. Patient is in the third trimester and placental location is questionable.
Answer 2: Pelvimetry, using x-ray films, would be used for nonpregnant patients who are planning to conceive, but have a history (injury or rickets) that could affect the shape of the pelvis. Palpation could be used for the patient in the first trimester. Ultrasound would be the imaging choice for confirming multiple fetuses and for placental localization.
The nurse is encouraging the mother to make frequent position changes during labor. Which position facilitates the second stage of labor by increasing the pelvic outlet? 1. Lateral side-lying 2. Squatting 3. Knee-chest 4. Lithotomy
Answer 2: Squatting facilitates the second stage of labor by moving the uterus forward and increasing the pelvic outlet. Many labor beds have squatting bars to support the laboring woman in this position. Left lateral side-lying is the position of choice if the mother is tired and wants to lie down. Knee-chest position is used if there is suspected cord compression with cord prolapse. Lithotomy position is often used for hospital deliveries.
The patient is 34 weeks gestation and reports an irregular tightening of the uterus and the health care provider (HCP) informs her that these are Braxton Hicks contractions. What additional information would the nurse give the patient? 1. Anticipate bloody show with Braxton Hicks contractions. 2. Call the HCP if the tightening sensations become painful and regular. 3. Anticipate that a headache and backache will accompany these contractions. 4. Expect leaking amniotic fluid will occur with Braxton Hicks contractions.
Answer 2: The nurse should instruct the patient to notify the HCP if the tightenings she is experiencing become painful and regular because this could indicate premature labor and the patient would need evaluation. The presence of bloody show or leaking amniotic fluid would not be normal with Braxton Hicks contractions. Backache can be normal, but a headache is not expected and could be a sign of hypertension.
Assessment of the amniotic fluid reveals yellow staining. What is the significance of this finding? 1. This is associated with hydramnios. 2. This finding is suggestive of intrauterine infection. 3. This color is common with abruptio placentae. 4. This staining is typical with meconium passage in utero.
Answer 2: Yellow staining of the amniotic fluid is associated with intrauterine infection or fetal hemolytic disease. The nurse might also note a foul odor to the fluid in cases of infection. Hydramnios is an excessive amount of fluid. Port wine color is associated with abruptio placentae. Greenish-brown color is associated with meconium-stained fluid.
What is an acceptable practice in labor and delivery? 1. Maintenance of a full bladder 2. Maintenance of supine position 3. Ambulation before membrane rupture 4. Administration of enemas in the presence of vaginal bleeding
Answer 3: Ambulation before rupture of membranes is encouraged because it provides distraction and tends to strengthen the effectiveness of labor. Full bladder can slow labor. Supine position is more uncomfortable and can compress the vena cava. Enemas are not given if vaginal bleeding is present, and are rarely used unless specifically indicated.
The woman is in the third trimester of pregnancy and the nurse observes that the woman's feet and ankles are unusually swollen. What is the most important assessment for the nurse to make? 1. Ask the woman if she has been resting and elevating her legs. 2. Assess the peripheral pulses and movement of the ankle joints. 3. Assess for edema of the face, presacral area, or fingers. 4. Ask the woman how much fluid she typical drinks in a day.
Answer 3: Assessment for generalized edema or edema in the face, fingers, or sacral area would be the next important observation by the nurse. Generalized edema can be suggestive of pre eclampsia and should be reported to the HCP. The nurse may also make the other assessments to follow up on the ankle edema.
The mother has diabetes and is at risk for placental insufficiency. The results of the nonstress test shows three fetal movements accompanied by two increases of 15 bpm in a 20-minute period. On hearing the results, she starts crying. What would the nurse be prepared to do for the patient? 1. Encourage the mother to express feelings of anxiety or uncertainty. 2. Prepare the mother for additional testing, such as the contraction stress test. 3. Reassure the mother that crying with relief and joy is an understandable response. 4. Support the mother through a repeat of the nonstress test for validation.
Answer 3: At least two fetal movements accompanied by two increases of 15 bpm in a 20-minute period indicate good fetal heart rate response to movement. The mother is likely to express feelings of relief if she knows that the baby is demonstrating reassuring signs of good health. If the fetal heart rate does not increase with fetal movement, additional testing is needed, and anxiety and uncertainty will continue.
The pregnant woman reports frequently feeling ill in the morning with bouts of nausea throughout the day. Which question is most important to differentiate between morning sickness and the more serious condition of hyperemesis gravidarum? 1. "How much and how frequently are you eating meals?" 2. "Do you notice that you are salivating more than usual?" 3. "Have you been vomiting? If yes, how frequently?" 4. "Are you experiencing heartburn? If yes, when does it occur?"
Answer 3: Hyperemesis gravidarum, which is excessive vomiting, can lead to dehydration, fluid and electrolyte imbalance, acid-base imbalance, altered kidney and cardiac function, and even fetal death. Asking the patient about the presence and frequency of vomiting would help determine if the condition is hyperemesis gravidarum or morning sickness. Small frequent meals are suggested for morning sickness and heartburn. Salivating and heartburn are gastrointestinal problems that may occur, but presence of these conditions does not help identify hyperemesis gravidarum.
The nurse is discussing sexual activity with the pregnant patient. Which advice would be correct? 1. Sexual intercourse in the first trimester can increase the risk of miscarriage. 2. Sexual intercourse should be avoided late in the third trimester. 3. Sexual intercourse is fine throughout pregnancy if there are no pregnancy complications. 4. Sexual intercourse increases the risk of spontaneous rupture of membranes.
Answer 3: In a normal pregnancy, sexual activity including intercourse is fine throughout the pregnancy. There is no need to routinely restrict sexual activity in any trimester of pregnancy. This advice would change if the pregnancy were complicated with bleeding, premature labor, or some placental implantation disorders.
The nurse is caring for a patient who has completed the third stage of labor. What is the purpose and goal of massaging the fundus? 1. Achieve uterine atony 2. Facilitate separation of the placenta 3. Regain uterine muscle tone 4. Determine the number and size of clots
Answer 3: Massaging the fundus is done to restore muscle tone. Atony (relaxation) of the uterus can lead to increased bleeding. Separation and expulsion of placenta complete the third stage of labor and the provider will assist as needed. Massaging will help expel clots, but observation is used to determine number and size.
Which factor would negate the woman's personal preference to use a birthing center? 1. Low-risk pregnancy 2. Unavailability of doula 3. Need for cesarean section 4. Limited insurance coverage
Answer 3: Need for a cesarean section or complications of pregnancy are contraindications. Birthing centers are ideal for women with lowrisk pregnancies. Doulas (trained in the care of the laboring family) can assist in any setting by choice of the family. Insurance coverage may influence a patient's choice of where to give birth, but would not negate her preference for a birthing center
The nurse is taking a health history and the information is likely to be used later during genetic counseling. Which question is the most appropriate in the initial data collection? 1. "How do you feel about undergoing genetic testing?" 2. "What would you do if an abnormality is detected?" 3. "Is there a family history of genetic diseases in the family? " 4. "Would you like information about genetic defects?"
Answer 3: Specifically asking about genetic diseases in the family helps to determine genetic risk for the current pregnancy. The nurse would need to specifically ask about certain genetic diseases like sickle cell anemia, hemophilia, or cystic fibrosis as the patient may not know which diseases in the family are genetic. The other questions would be more appropriate later if the patient is considering genetic testing.
What would the nurse tell the patient who has noted facial swelling in the third trimester of pregnancy? 1. "This is a temporary condition caused by increased blood flow resulting from high estrogen levels." 2. "An increased blood volume results in increased water retention, but the swelling should go away." 3. "Facial swelling is something that has to be reported to your HCP for follow-up care and evaluation." 4. "This should be reported to your provider because swelling signals an increased amount of melanocyte-stimulating hormone."
Answer 3: Swelling of the face is one of the danger signs that should be reported to the HCP. It could be indicative of pre eclampsia and requires further evaluation. Increased blood flow from high estrogen levels causes reddened palms or spider nevi. Increased blood volume is expected, but this alone does not cause water retention. Increased amounts of melanocyte-stimulating hormone cause benign changes in skin coloration.
The nurse informs the mother that the results of the nitrazine test are blue-green, pH 6.5. What additional information would the nurse give to the mother? 1. Advise her that precipitous labor is likely. 2. Instruct her to go home and resume usual activity. 3. Inform her that labor will likely start soon. 4. Tell her that the test is nonreactive and that urine leakage is normal.
Answer 3: The nitrazine test is positive showing an alkaline sample which would suggest amniotic fluid. Due to this, the patient would be informed that labor will likely start soon, and if not, the HCP may begin induction of labor. The nurse would notify the HCP of the probable leaking of amniotic fluid. Precipitous labor is rapid labor that lasts less than 3 hours. Depending on the advice of the HCP, the patient may be able to go home and get organized to report for admission to the hospital, but would not resume normal activities.
The patient is experiencing a prolonged but progressive labor in which both she and the fetus are doing well. The father of the baby is irritable and complains repeatedly to the nurse that this is taking too long. What would be the best response from the nurse? 1. "Is there another family member who could take your place here?" 2. "Labor can take a very long time. You need to think of what your wife is experiencing and how long it must seem to her." 3. "It is a long labor, but all is going well. If you would like to take a break and get some food, I will stay with your wife until you return." 4. "Please go home and take a nap and come back when you feel ready to be helpful."
Answer 3: The nurse would acknowledge that the labor is long, reassure the father that all is going well, and encourage him to get some food to meet his own needs and welcome him back upon his return, give him an update and help him see how he can assist his partner. His complaining may reflect his lack of food and rest, his anxiety over the process or his lack of knowledge of how long labor can last. Telling him to get someone else to take his place minimizes his role. Telling him to think of what his wife is going through attempts to make him feel guilty, and telling him to go home and come back when he can be more helpful is punitive.
The woman received general anesthesia for a cesarean section. Because the mother has increased risk for uterine relaxation, which action will the nurse perform? 1. Administer glycopyrrolate as prescribed. 2. Monitor for increased abdominal pain. 3. Monitor for postpartum hemorrhage. 4. Administer magnesium sulfate.
Answer 3: Uterine relaxation could result in postpartum hemorrhage. Glycopyrrolate (Robinul) is given to reduce secretions and decrease the risk of aspiration. Magnesium sulfate is given to prevent seizures associated with preeclampsia or eclampsia. Abdominal pain is likely to be associated with the procedure, not the anesthetic.
Following a precipitous labor and emergency birth, what is likely to be the greatest concern? 1. Grief and loss due to fetal demise 2. Prolonged contractions and abdominal pain 3. Severe hypertension and seizures 4. Postpartum hemorrhage and hypovolemia
Answer 4: A precipitous labor may result from hypertonic contractions and lower than normal resistance in the maternal soft tissues. Potential maternal complications include uterine rupture, lacerations of the birth canal, amniotic fluid embolism, and postpartum hemorrhage.
The mother is in her second trimester and reports "premilk" is leaking from her breasts. What would the nurse tell the mother? 1. "Any discharge from the nipples should be considered abnormal and evaluated by the HCP." 2. "Premilk or colostrum is not supposed to start until immediately after delivery." 3. "Premilk will be pumped and discarded in order to stimulate the true breast milk." 4. "If excessive leakage is a problem, breast pads can be useful."
Answer 4: Colostrum flow in the second trimester is considered normal. Suggest use of breast pads to control excessive flow. The patient would not be advised to pump her breasts at this time to obtain colostrum because pumping can stimulate labor.
The HCP informs the nurse that the patient has chosen to try for a vaginal birth after cesarean (VBAC). Which practice would be appropriate in the care of this patient during labor? 1. Restrict position changes. 2. Use misoprostol for induction of labor. 3. Avoid use of epidural anesthesia. 4. Utilize continuous fetal monitoring.
Answer 4: Continuous fetal monitoring is usually used with women attempting VBAC. Changes in the fetal heart rate on the continuous monitor can be the first sign of uterine rupture. Position changes are helpful in any labor to encourage the process of labor. Nursing actions in helping women change positions can increase the success rate of VBACs. Misoprostol is not recommended for induction of labor in women with a prior cesarean section. An epidural can be utilized during a VBAC.
After delivery, the nurse is examining the placenta. Which is the most important observation that the nurse would note and document? 1. Weight of the placenta 2. Presence of the placental barrier 3. Appearance of the "Shiny Schultz" 4. Intactness of the placenta
Answer 4: Note the intactness of the placenta; bleeding and infection can occur if fragments of the placenta are retained in the uterus. The placenta would be weighed and the presentation of the fetal side (Shiny Schultz) versus uterine wall (Dirty Duncan) should be noted. Placental barrier refers to the ability of the placenta to filter bacteria and some other substances.
The pregnant patient at 37 weeks gestation phones the clinic and reports having some symptoms that are causing discomfort and worry. Which symptom is the most serious and warrants immediate evaluation by the HCP ? 1. Shortness of breath when climbing the stairs 2. Perineal discomfort and pressure with standing 3. Muscle aches and difficulty walking 4. Pain and burning sensation with urination
Answer 4: Pain and burning with urination signal a urinary tract infection. Infection is one of the dangers that require evaluation. The other symptoms are likely as the pregnancy advances.
Which behaviors/symptoms would be considered normal and expected a few days before onset of true labor? 1. Depression and fatigue 2. Vomiting and loss of appetite 3. A loss of 5-10 pounds 4. Renewed energy for cooking and cleaning
Answer 4: Renewed energy for nesting behaviors can occur. Nausea and diarrhea are not uncommon and weight loss of 1-3 pounds may occur. Depression is not expected at this time.
The neonate has just been delivered. What is an indication that placental separation is occurring? 1. Uterus is relaxed and flaccid. 2. Blood can no longer be milked from the umbilical cord. 3. Contractions are progressively weaker. 4. The umbilical cord is obviously lengthening.
Answer 4: Signs of placental separation include firmly contacting fundus, ovoid-shaped uterus, gush of dark red blood, lengthening of umbilical cord, and vaginal fullness.
The woman is in the first trimester of pregnancy and tells the nurse that she has morning sickness almost every day. Which intervention would the nurse suggest first? 1. Taking an over-the-counter antacid 2. Keeping a daily symptom diary 3. Drinking a tea made of ginger root 4. Nibbling a few soda crackers before rising
Answer 4: The nurse would first suggest trying a few soda crackers. Ginger is an alternative therapy to be considered. The nurse may have protocols to work from when giving advice to prenatal patients. The HCP might need to be consulted as indicated by institutional protocol before making some recommendations to patients. The nurse must be sure that advice that she gives is safe and evidence-based. The symptom diary might help if diet and activity are possible trigger factors. An antacid would typically be more helpful in later pregnancy with symptoms of heartburn.
The HCP informs the nurse that there is a prolapsed umbilical cord. What would the nurse do first? 1. Assist the mother into a high Fowler's position. 2. Apply a fetal monitoring device and count heart rate. 3. Prepare the mother for a cesarean birth. 4. Ensure that the HCP has sterile gloves.
Answer 4: The provider can relieve pressure on the cord by putting on a sterile glove and holding the presenting part off of the umbilical cord. Mother could be assisted into a modified left lateral recumbent, Trendelenburg, or kneechest position. The fetal heart rate would be carefully monitored for changes and cesarean birth may be necessary.
On examination, the patient is found to be 8 cm dilated with contractions every 3 minutes that last for 70 seconds. Which behavior is likely to occur in this transitional phase? 1. Alert and talkative 2. Confused and disoriented 3. Less talkative and focused on breathing 4. Irritable and deeply focused
Answer 4: The transitional phase is the last phase of the first stage of labor. The woman is deeply focused and may not wish to communicate with the nurse or significant other. She may be easily irritated by distractions. If the woman has not requested pain medication earlier, she may desire it at this time. Nausea is common. Confusion and disorientation is not expected and may signal problems with oxygenation and perfusion.
A woman comes to the clinic for her first prenatal visit. The nurse asks when her first day of her last menstrual cycle was. The woman reports July 10, 2004. What would the nurse calculate her estimated date of delivery to be using the Naegele rule? April 17, 2005 March 17, 2005 April 3, 2005 March 3, 2005
April 17, 2005
Which characteristics are indications of true labor? (Select all that apply.) Contractions follow a regular pattern. The cervix softens, effaces, and dilates. Contractions may be felt in the back but are most often noticed in the fundus. Contractions get stronger with ambulation. Each contraction gets longer and longer.
Contractions follow a regular pattern. The cervix softens, effaces, and dilates. Contractions get stronger with ambulation.
A pregnant patient comes to the hospital saying she thinks her water has broken. The nurse checks the fluid with Nitrazine test paper to determine if the fluid is amniotic fluid or vaginal secretions. What color will the nurse expect the paper to turn if the fluid is amniotic? Olive-green Deep blue Olive-yellow Yellow
Deep blue
A pregnant patient comes to the clinic for a prenatal visit. She complains of being frequently awakened at night by leg cramps. What instructions should the nurse give this patient? Plantar flex her foot when the cramp occurs. Have her spouse rub her leg until the cramp goes away. Dorsiflex her foot when the cramp occurs. Walk around the room till the cramp goes away.
Dorsiflex her foot when the cramp occurs.
What is the term for shortening and thinning of the cervix during the first stage of labor? Dilation Effacement Contractions Scarring
Effacement
When assessing cultural preferences of a laboring patient, the nurse remembers to ask about traditional birth practices. Which birth practice is most common in non-American cultures? Stoic about pain Bury the placenta Father is not present Father and female relatives present
Father is not present
Based on the definitions of gravida and para, what documentation best describes a woman in the clinic who is currently pregnant and has had two prior children? Gravida I, para I Gravida II, para I Gravida III, para II Gravida II, para II
Gravida III, para II
The health care provider is performing the Leopold maneuver on a laboring patient to check for fetal position. What is the most common position for delivery? ROP ROA LOP LOA
LOA
While assessing a laboring patient, which fetal heart tone (FHT) would the nurse consider cause for further or constant monitoring? Early deceleration Accelerations FHT at 136 beats/min Late deceleration
Late deceleration
The nurse is caring for a patient in labor. While assessing the patient's vital signs, the nurse notes a drop in the patient's blood pressure. To prevent supine hypotension, the nurse should encourage the patient to be in what position? Trendelenburg Left lateral side lying Right lateral side lying Supine
Left lateral side lying
The laboring patient has just had membranes ruptured by the health care provider. The amniotic fluid is greenish-brown in color. What does this abnormal finding indicate? Premature separation of the placenta Intrauterine infection Passage of meconium stool by the fetus Fetal hemolytic disease
Passage of meconium stool by the fetus
A pregnant patient complains of having to go to the bathroom frequently and sometimes even has stress incontinence. What can the nurse teach the patient to do to increase the tone of the perineum muscles? Perform pelvic tilt exercises. Perform Kegel exercises. Wear an abdominal support. Avoid waiting so long to go to the bathroom.
Perform Kegel exercises.
When the delivery of the placenta is complete, which stage of labor is complete? First stage Second stage Third stage Fourth stage
Third stage
