HESI
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? 1 First 2 Second 3 Prodromal 4 Transitional
1 First The first stage of labor is from 0 to 10cm dilation The second stage is from full dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.
The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment? 1 Drink fluids 2 Empty her bladder 3 Perform the Valsalva maneuver 4 Assume the semi-Fowler position
2 Empty her bladder Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side.
In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time? 1 Having the client empty her bladder 2 Watching for signs of retained secundines 3 Massaging the uterus vigorously to prevent hemorrhage 4 Explaining to the client that this is a sign of uterine stabilization
Having the client empty her bladder A full bladder elevates the uterus and displaces it to the right.
During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do? 1 Breathe into her cupped hands 2 Pant during the next three contractions 3 Hold her breath with the next contraction 4 Use a fast, deep, or shallow breathing pattern
1 Breathe into her cupped hands
A client is scheduled for a nonstress test in the 37th week of gestation. The nurse explains the procedure. Which statement demonstrates that the client understands the teaching? 1 "I'll need to have an IV so the medication can be injected before the test." 2 "My baby may get very restless after I have this test." 3 "I hope this test doesn't cause my labor to start too early." 4 "If the heart reacts well, my baby should do OK when I give birth."
"If the heart reacts well, my baby should do OK when I give birth."
A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief? 1 "Eat dry crackers before you get out of bed." 2 "Increase your fat intake before bedtime." 3 "Drink high-carbohydrate fluids with meals." 4 "Eat two small meals a day and a snack at noon."
1 "Eat dry crackers before you get out of bed."
A pregnant client uses a computer while sitting almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend? 1 "Try to walk around every few hours during the workday." 2 "Ask for time in the morning and afternoon to elevate your legs." 3 "Tell your boss that you won't be able to work beyond the second trimester." 4 "Ask for time in the morning and afternoon so you can go get something to eat."
1 "Try to walk around every few hours during the workday."
Which statements regarding the involution process are correct? Select all that apply. 1 Involution begins immediately after expulsion of the placenta. 2 Involution is the self-destruction of excess hypertrophied tissue. 3 Involution progresses rapidly during the next few days after birth. 4 Involution is the return of the uterus to a nonpregnant state after birth. 5 Involution may be caused by retained placental fragments and infections.
1, 3, 4 1. Involution begins immediately after expulsion of the placenta. 3. Involution progresses rapidly during the next few days after birth. 4. Involution is the return of the uterus to a nonpregnant state after birth. The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.
Which cervical changes are observed during pregnancy? Select all that apply. 1 The cervical tip becomes soft. 2 The fragility of cervical tissues decreases. 3 The volume of cervical muscles increases. 4 The external cervical os appears as a jagged slit. 5 The elasticity of cervical collagen-rich connective tissue increases.
1, 3, 5 1 The cervical tip becomes soft. 3 The volume of cervical muscles increases. 5 The elasticity of cervical collagen-rich connective tissue increases. By the beginning of the sixth week of pregnancy, the cervical tip softens. During pregnancy, the cervical muscles and its collagen-rich connective tissues increase in volume and become loose and highly elastic. Cervical tissue fragility also increases. The external cervical os appears as a jagged slit postpartum; however, not during pregnancy.
The nurse observes a laboring client's amniotic fluid and decides that it is the expected color and consistency. Which finding supports this conclusion? 1 Clear, dark amber colored, and containing shreds of mucus 2 Straw-colored, clear, and containing little white specks 3 Milky, greenish yellow, and containing shreds of mucus 4 Greenish yellow, cloudy, and containing little white specks
2 Straw-colored, clear, and containing little white specks By 36 weeks' gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.
A pregnant client asks the clinic nurse how smoking will affect her baby. What information about cigarette smoking will influence the nurse's response? 1 It relieves maternal tension, and the fetus responds accordingly to the reduction in stress. 2 The resulting vasoconstriction affects both fetal and maternal blood vessels. 3 Substances contained in smoke diffuse through the placenta and compromise the fetus's well-being. 4 Effects are limited because fetal circulation and maternal circulation are separated by the placental barrier.
2 The resulting vasoconstriction affects both fetal and maternal blood vessels. Cigarette smoking or continued exposure to secondary smoke causes both maternal and fetal vasoconstriction, resulting in fetal growth retardation and increased fetal and infant mortality. There is no clinical evidence that smoking relieves tension or that the fetus is more relaxed. Smoking causes vasoconstriction; permeability of the placenta to smoke is irrelevant. Although the fetal and maternal circulations are separate, vasoconstriction occurs in both mother and fetus.
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question? 1 Usually fluctuate in length 2 Continuous, without relaxation 3 Related to time of membrane rupture 4 Accompanied by progressive cervical dilation
Accompanied by progressive cervical dilation
What is the optimal nursing intervention to minimize perineal edema after an episiotomy? 1 Applying ice packs 2 Offering warm sitz baths 3 Administering aspirin as needed (prn) 4 Elevating the hips on a pillow
1 Applying ice packs Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.
A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments? 1 Report the findings because the client needs immediate intervention. 2 Document the results because they are expected at 20-weeks' gestation. 3 Record the findings in the medical record because they are not within the norm but are not critical. 4 Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.
2 Document the results because they are expected at 20-weeks' gestation.
A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? 1 Kidney defects 2 Cardiac anomalies 3 Neural tube defects 4 Urinary tract anomalies
3 Neural tube defects
A client in her 37th week of gestation calls the nurse at the clinic and reports, "My ankles are so swollen." Which intervention should the nurse recommend? 1 Limiting fluid intake during the day 2 Elevating her legs more frequently during the day 3 Restricting salt intake for the remainder of her pregnancy 4 Taking a mild diuretic that the healthcare provider will prescribe
Elevating her legs more frequently during the day
The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? 1 From the end of one contraction to the end of the next contraction 2 From the end of one contraction to the beginning of the next contraction 3 From the beginning of one contraction to the end of the next contraction 4 From the beginning of one contraction to the beginning of the next contraction
4 From the beginning of one contraction to the beginning of the next contraction
A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram? 1 Empty her bladder. 2 Avoid eating for 8 hours. 3 Take a laxative the night before the test. 4 Increase fluid intake for 1 hour before the procedure.
4 Increase fluid intake for 1 hour before the procedure.
A postpartum client tells the nurse that she wishes to breast-feed. When the nurse brings her newborn to be breast-fed, the client asks whether she may drink a small glass of wine to help her relax. How should the nurse respond? 1 "I think drinking one glass of wine won't be a problem. Go ahead." 2 "You seem a little tense. Tell me how you feel about breast-feeding." 3 "You seem to find it relaxing, but you should try to find another way to relax." 4 "I think drinking one glass of wine is alright, but you had better check with your doctor first."
2 "You seem a little tense. Tell me how you feel about breast-feeding." Stating that the client seems tense and initiating a discussion honors the client's feelings and encourages expression of them; there is no reference to alcohol consumption and its relaxing effects.
The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? 1 Prolong the course of labor 2 Cause decreased placental perfusion 3 Lead to transient episodes of hypertension 4 Interfere with free movement of the coccyx
2 Cause decreased placental perfusion In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.
On a routine prenatal visit, what is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? 1 Quickening 2 Palpitations 3 Pedal edema 4 Vaginal spotting
1 Quickening The recognition of fetal movement commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting at this time requires immediate follow-up care.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. How should the nurse respond? 1 "These accelerations are a sign of fetal well-being." 2 "These accelerations indicate fetal head compression." 3 "Umbilical cord compression is causing these accelerations." 4 "Uteroplacental insufficiency is causing these accelerations."
1 "These accelerations are a sign of fetal well-being." The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.
A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take? 1 Discontinuing the test because the pattern is within the normal range 2 Encouraging the client to drink more fluids to decrease the fetal heart rate 3 Notifying the primary healthcare provider and preparing for an emergency birth 4 Recording this nonreassuring pattern and continuing the test for further evaluation
1 Discontinuing the test because the pattern is within the normal range The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period.
The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what? 1 Estimate fetal age 2 Detect hydrocephalus 3 Rule out congenital defects 4 Approximate fetal linear growth
1 Estimate fetal age
What common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? 1 Intrusion on movement 2 Inability to take sedatives 3 Interference with breathing techniques 4 Increased frequency of vaginal examinations
1 Intrusion on movement Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.
A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the client at this time? 1 The cervix dilates and becomes effaced in true labor. 2 Bloody show is the first sign of true labor. 3 The membranes rupture at the beginning of true labor. 4 Fetal movements lessen and become weaker in true labor.
1 The cervix dilates and becomes effaced in true labor. The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix.
Which statement made by a pregnant client to a nurse indicates that the client does not understand the teaching regarding fetal growth and development? 1 "The baby is smaller if the mother smokes." 2 "The baby gets food from the amniotic fluid." 3 "The baby's oxygen is provided by the mother." 4 "The baby's umbilical cord has two arteries and one vein."
2 "The baby gets food from the amniotic fluid." The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen.
The nurse is preparing to counsel a client whose two previous pregnancies were uneventful, ending in term vaginal births of healthy children. What should the nurse consider regarding multiparas with previous uneventful pregnancies before beginning prenatal counseling? 1 Multiparas cope more successfully with pregnancy than do primigravidas. 2 Each pregnancy is a unique experience that is stressful despite multiparity. 3 This pregnancy will provoke a situational crisis because the client has two children at home. 4 Support people play a lesser role because the client has had two prior experiences with pregnancy.
2 Each pregnancy is a unique experience that is stressful despite multiparity.
A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? 1 Increasing the infusion rate 2 Checking for a distended bladder 3 Continuing to perform fundal massage 4 Continuing to assess the blood pressure
2 Checking for a distended bladder A displaced and boggy uterus is usually the result of a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus. If still boggy, the uterus should be massaged until firm. The oxytocin infusion may need to be increased if voiding and fundal massage are ineffective; however, the healthcare provider must be notified to change the order. Continuing to perform fundal massage is necessary if the fundus remains boggy after the client has voided. Continuing to assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the priority.
While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next? 1 Change the bedding. 2 Notify the practitioner. 3 Assess the fetal heart rate (FHR). 4 Obtain the client's blood pressure.
3 Assess the fetal heart rate (FHR). The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR.
During an emergency birth the fetal head is crowning on the perineum. How should the nurse support the head as it is being delivered? 1 By applying suprapubic pressure 2 By placing a hand firmly against the perineum 3 By distributing the fingers evenly around the head 4 By maintaining pressure against the anterior fontanel
3 By distributing the fingers evenly around the head
The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first? 1 Notify the practitioner. 2 Elevate the head of the bed. 3 Reposition her on her left side. 4 Administer oxygen by way of face mask.
3 Reposition her on her left side. Late decelerations may indicate impaired placental profusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the practitioner is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented.
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? 1. Scant alba 2. Scant rubra 3. Moderate rubra 4. Moderate serosa
3. Moderate rubra The uterus sloughs off the blood, tissue, and mucus of the endometrium postdelivery. This happens in three stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the FIRST and heaviest stage of lochia. The blood that's expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for about seven days. Lochia serosa is the SECOND stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts about two weeks although for some women it can last up to four to six weeks postpartum. Lochia alba is the FINAL stage of lochia, rather than blood you'll see a white or yellowish discharge that's generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around six weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than two weeks.
What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? 1 "I will take a cool shower before each feeding." 2 "I will drink a couple of quarts of fat-free milk a day." 3 "I will wear a snug-fitting breast binder day and night." 4 "I will apply warm packs and massage my breasts before each feeding."
4 "I will apply warm packs and massage my breasts before each feeding." Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation
One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? 1 Encourage the client to void. 2 Notify the practitioner immediately. 3 Massage the uterus and attempt to express clots. 4 Continue periodic assessments and record the findings.
4 Continue periodic assessments and record the findings. Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded. Encouraging the client to void is unnecessary; if the bladder is full, the uterus will be higher and pushed to one side. Notifying the healthcare provider is unnecessary; involution is occurring as expected. Massage is used when the uterus is soft and "boggy."
