Maternal-Newborn
D
A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase
A
A breastfeeding woman with sore nipples should be advised to ___ A. ensure that the infant has proper latch on to the breast B. limit the feeding time on each breast C. wash her breasts frequently with soap and water
C
A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms? A. Hysteria compounded by the flu B. Placental abruption C. Uterine rupture D. Dysfunctional labor
3
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Insert eye prophylaxis. 2. Elicit the Moro reflex. 3. Remove wet blankets. 4. Assess Apgar score.
D
A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? A. Gender of the fetus B. Fetal position C. Labor progress D. Oxygenation
A
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria
C
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond? A. Let the client get up to use the potty B Allow the client to use a bedpan C. Perform a pelvic examination D. Check the fetal heart rate
C
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of pitocin IV infusion
A
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A. Place the client in Trendelenburg's position B. Call the delivery room to notify the staff that the client will be transported immediately C. Gently push the cord into the vagina D. Find the closest telephone and stat page the physician
C
A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. Absence of abdominal pain B. A soft abdomen C. Uterine tenderness/pain D. Painless, bright red vaginal bleeding
C
A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? A. Medication that will provide sedation B. Increased hydration C. Oxytocin (Pitocin) infusion D. Administration of a tocolytic medication
A
A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen C. Notify the physician or nurse midwife of the findings D. Reposition the mother and check the monitor for changes in the fetal tracing
D
A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: A. Noting if the heart rate is greater than 140 BPM B. Placing the diaphragm of the Doppler on the mother abdomen C. Performing Leopold's maneuvers first to determine the location of the fetal heart D. Palpating the maternal radial pulse while listening to the fetal heart rate
D
A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A. The client begins to expel clear vaginal fluid B. The contractions are regular C. The membranes have ruptured D. The cervix is dilated completely
D
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? A. Encourage the client's coach to continue to encourage breathing exercises B. Encourage the client to continue pushing with each contraction C. Continue monitoring the fetal heart rate D. Notify the physician or nurse midwife
B
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A. Early decelerations B. Variable decelerations C. Late decelerations D. Short-term variability
A
A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? A. Fetal heart rate of 180 beats per minute B. White blood cell count of 12,000 C. Maternal pulse rate of 85 beats per minute D. Hemoglobin of 11.0 g/dL
A
A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: A. 1 cm above the ischial spine B. 1 fingerbreadth below the symphysis pubis C. 1 inch below the coccyx D. 1 inch below the iliac crest
4
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Apply pulse oximeter. 2. Administer oxygen. 3. Place child in isolette. 4. Swaddle baby in blanket.
1
A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? 1. Endometritis 2. Endometriosis 3. Salpingitis 4. Pelvic thrombophlebitis
C
A predisposing factor for assisted delivery (forceps or vacuum) is ___? A. adolescent pregnancy B. multiparity C. post dates gestation
B
A preeclamptic woman in the immediate postpartum period needs to be monitored closely for elevated blood pressure and ___? A. adult respiratory distress syndrome B. onset of seizures C. subdural hematoma D. Hypoglycemia
D
A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A. A loud mouth B. Low self-esteem C. Hemorrhage D. Postpartum infections
A
A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: A. Tailor sitting B. Leg lifting C. Shoulder circling D. Squatting exercises
4
A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? 1. Back 2. Abdomen 3. Fundus 4. Perineum
4 (If the fetus is not engaged in the pelvic inlet, there is a danger that the umbilical cord will prolapse. The healthcare provider should assess the fetal heart rate to ensure fetal well-being.)
A primigravida in preterm labor at 34 weeks gestation feels a sudden gush of water and tells the healthcare provider, "I think my water broke." What is the priority action by the healthcare provider? 1. Prepare for imminent delivery 2. Take the woman's temperature 3. Assess the degree of cervical dilation 4. Assess the fetal heart rate
C
After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus at the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin
4
After the birth of a newborn, what is the priority nursing action to prevent cold stress? 1. Swaddle in warm blankets 2. Place under a radiant warmer 3. Place a stocking cap on the neonate's head 4. Dry the neonate thoroughly
Chadwick's sign
Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion; probable sign
4-7 cm
Cervix dilation, active phase (stage 1 of labor)
1-4 cm
Cervix dilation, latent phase (stage 1 of labor)
7-10 cm
Cervix dilation, transition phase (stage 1 of labor)
Presentation
Determined by the part of the fetus that first enters the pelvic inlet
A
Fetal presentation refers to which of the following descriptions? A. Fetal body part that enters the maternal pelvis first B. Relationship of the presenting part to the maternal pelvis C. Relationship of the long axis of the fetus to the long axis of the mother D. A classification according to the fetal part
1
Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is high risk for physiological jaundice? 1. Cephalhematoma. 2. Mongolian spotting. 3. Caput succedaneum. 4. Harlequin coloring.
D
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby B. Recognize this as a behavior of the taking-hold stage C. Record the behavior as ineffective maternal-newborn attachment D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
Pregnancies
Gravidity: refers to # of ___
B
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: A. Change the woman's position B. Stop the Pitocin C. Elevate the woman's legs D. Administer oxygen via a tight mask at 8 to 10 liters/minute
Radiation
Loss of heat from body to cooler surface that is close to but not in direct contact
Cyanotic
Oxygenation may be a treatment used neonates that are ___
Preterm (<37 weeks)
P is ___ births
Births/deliveries past 20 weeks
Parity: refers to # of ___
Gentle stimulation
Regarding APGAR scores, what may improve neonate health at 1 minute postnatally if in distress?
Fetal position
Relation of the presenting part to maternal pelvis
Fetal attitude or posture
Relationship of fetal parts to one another
Fetal lie
Relationship of the long axis of the fetus to the long axis of the mother
Births (>37 weeks)
T is term ___
Powers Passage Passenger Position Psyche
The 5 essential factors of labor
5, 6 (apply suprapubic pressure, NOT on fundus)
The healthcare provider is caring for a woman during the birth of her baby. As the fetal head is delivered, the healthcare provider notes that the head retracts against the mother's perineum ("turtle sign"). What actions will the healthcare provider implement? Select all that apply: 1. Apply fundal pressure 2. Attempt delivery with forceps 3. Empty the woman's bladder 4. Ask the woman to begin pushing 5. Flex the woman's thighs against her abdomen 6. Call for assistance
1
The healthcare provider is caring for a woman who is in active labor at 40 weeks gestation. Which of the following best describes the correct placement of the external tocotransducer to monitor uterine activity? 1. Near the uterine fundus 2. Midline on the lower abdomen 3. Just above the symphysis pubis 4. Over the umbilicus
1, 4, 5
The nurse is assessing the head of a newborn. Which assessment data does the nurse document as a normal finding? Select all that apply. 1. Fontanels soft and flat 2. Anterior fontanel triangle shaped at 3 cm 3. Posterior fontanel diamond shaped at less than 1 cm 4. Molding present with overriding sutures 5. Fontanels bulge when crying
4
The nurse is assigned four newborns in the nursery. Which newborn should the nurse report to the physician? 1. 23-hour-old neonate who has not passed meconium 2. Six-hour-old neonate who is large for gestational age with a glucose of 41 3. 2-day-old neonate who has a blood-tinged vaginal discharge 4. 2-day-old neonate with irregular respirations at 70 per minute
1
The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: 1. "Nausea and vomiting can be decreased if I eat a few crackers before arising" 2. "If I start to leak colostrum, I should cleanse my nipples with soap and water" 3. "If I have a vaginal discharge, I should wear nylon underwear" 4. "Leg cramps can be alleviated if I put an ice pack on the area"
3
The nurse is performing an assessment on the client who is 38 weeks and notes FHR is 174 bpm. On the basis of this finding, what is the priority nursing action? 1. Document 2. Check mother's HR 3. Notify OB 4. Tell client the FHR is normal
C
The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day B. Wearing a supportive brassiere with nipple shields C. Breast-feeding the neonate at frequent intervals D. Decreasing fluid intake for the first 24 to 48 hours
D
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. Severe postpartum headache B. Limited perception of bladder fullness C. Increase in respiratory rate D. Hypotension
1, 2, 3, 4
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics? Select all that apply: 1. allows fetal movement 2. surrounds, cushions, & protect fetus 3. maintains body temp of fetus 4. can be used to measure fetal kidney function 5. prevents large particles such as bacteria from passing to fetus
A
Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines B. Effacement is 4 cm from completion C. Dilation is 50% completed D. Fetus has achieved passage through the ischial spines
Flaccid
What would earn a 0 on the activity & muscle tone portion of APGAR?
Entire body is blue or pale
What would earn a 0 on the appearance portion of APGAR?
No response
What would earn a 0 on the grimace portion of APGAR?
Absent
What would earn a 0 on the pulse portion of APGAR?
Absent
What would earn a 0 on the respiration portion of APGAR?
Slight flexion
What would earn a 1 on the activity & muscle tone portion of APGAR?
Extremities are blue
What would earn a 1 on the appearance portion of APGAR?
Grimace
What would earn a 1 on the grimace portion of APGAR?
Slow (<100 bpm)
What would earn a 1 on the pulse portion of APGAR?
Slow or irregular breathing
What would earn a 1 on the respiration portion of APGAR?
Good flexion
What would earn a 2 on the activity & muscle tone portion of APGAR?
Entire body is pink
What would earn a 2 on the appearance portion of APGAR?
Grimace with crying or sneezing or coughing
What would earn a 2 on the grimace portion of APGAR?
Normal (>100 bpm)
What would earn a 2 on the pulse portion of APGAR?
Regular or crying
What would earn a 2 on the respiration portion of APGAR?
4
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? 1. Turn the neonate every 6 hours 2. Encourage the mother to discontinue breast-feeding 3. Notify the physician if the skin becomes bronze in color 4. Check the vital signs every 2 to 4 hours
Ampulla (of fallopian tube)
Where does fertilization occur?
C
Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B. Encourage the woman to void every 2 hours C. Massage the fundus every hour for the first 24 hours following birth D. Teach the woman the importance of rest and nutrition to enhance healing
3
Which of the following neonates is at highest risk for cold stress syndrome? 1. Down syndrome neonate. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Infant of diabetic mother.
D
Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? A. Notify the neonate's pediatrician immediately B. Check the diaper and circumcision again in 30 minutes C. Secure the diaper tightly to apply pressure on the site D. Apply gentle pressure to the site with a sterile gauze pad
B
Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Titanic uterine contractions D. Premature rupture of membranes
3, 5
Which purposes of placental functioning should the nurse include in the prenatal class? Select all that apply: 1. it cushions & protects baby 2. it maintains the temp of baby 3. it is the way the baby gets food & oxygen 4. it prevents all antibodies & viruses from passing to baby 5. it provides an exchange of nutrients & waste products between mother and fetus
B
While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? A. Note the fetal heart rate patterns B. Notify the physician immediately C. Administer oxygen at 6 liters by mask D. Have the client pant-blow during the contractions
Fertilization
aka conception
2-3 months
how long does the blastocyst secrete HCg
Placenta previa
implantation of the placenta over the cervical opening or in the lower region of the uterus
110-160
normal FHR
Chorion
outer membrane that encloses the amniotic cavity
Obstectrics
practice of caring for pregnant & postpartum women & women attempting to become pregnant
Ballotement
rebound of unengaged fetus; probable sign
Goodell's sign
softening of the cervix; probable sign
Hegar's sign
softening of the lower uterine segment; probable sign
Convection
the flow of heat from the body surface to cooler air
Evaporation heat loss
the loss of heat that occurs when a liquid is converted to a vapor
Foramen ovale, atria, lungs
this fetal bypass is the opening between the right & left ___; bypasses the ___
Ductus venosus, vein, inferior liver
this fetal bypass that connect umbilical ___ & ___ vena cava; bypasses the ___
Ductus ateriosus, lungs
this fetal bypass that connects the pulmonary artery to aorta; bypasses the ___
Vein
umbilical ___ carries oxygenated blood & nutrients to fetus from placenta
Arteries
umbilical ___ carry deoxygenated blood & waste away from fetus
Sperm & ovum unite
when does fertilization occur? Meaning, what's the moment?
6-8 days after ovulation
when does implantation occur?
