Maternity
A woman telephones her health care provider and reports that her waters just broke. Which suggestion by the nurse would be most appropriate?
"Come to the clinic or emergency department for an evaluation."
The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?
"I need to lie flat on my back to perform the procedure."
After teaching a woman who has had an evacuation for a hydatidiform mole (molar pregnancy) about her condition, which of the following statements indicates that the nurse's teaching was successful?
"I will be sure to avoid getting pregnant for at least 1 year."
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instructions?
"I will begin abdominal exercises immediately."
A nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?
"I will need to increase my insulin dosage during the first 3 months of pregnancy." - Insulin needs decrease in the 1st trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which of the following responses by the nurse would be most appropriate?
"I'm sorry you lost your baby."
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?
"My contractions will increase in duration and intensity."
A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?
"The contractions slow down when I walk around."
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?
"The temperature of the water should be at least 105 degrees F."
After describing continuous electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching?
"Unfortunately, I'm going to have to stay quite still in bed while it is in place."
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?
"When I put on a new pad, I'll start at the back and go forward."
The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid?
- Allows for fetal movement - Surrounds, cushions, and protects the fetus - Maintains the body temperature of the fetus - Can be used to measure fetal kidney function
The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note?
- Bright reg vaginal bleeding - Soft, relaxed, nontender uterus - Fundal height may be greater than expected for gestational age
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring
2
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? 1.Early decelerations 2.Variable decelerations 3.Late decelerations 4.Short-term variability
2
While providing care to a woman who is experiencing postpartum hemorrhage, the nurse weighs her perineal pads to estimate blood loss. The pad weighs 20 g. The nurse documents this as which amount?
20 mL
A 10-week pregnant woman with diabetes has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which of the following possible fetal outcomes? A) Congenital anomalies B) Incompetent cervix C) Placenta previa D) Abruptio placentae
A
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which of the following in the mother and the newborn? A) Infection B) Hemorrhage C) Trauma D) Hypovolemia
A
A maternal complication that can result from diabetes mellitus is: a. Hydramnios b. Endometriosis c. Hypotension d. Alkalosis
A
A multipara client develops thrombophlebitis after delivery. Which of the following would alert the nurse to the need for immediate intervention? A) Dyspnea, diaphoresis, hypotension, and chest pain B) Dyspnea, bradycardia, hypertension, and confusion C) Weakness, anorexia, change in level of consciousness, and coma D) Pallor, tachycardia, seizures, and jaundice
A
A nurse is caring for a woman who has been hypertensive since her thirty-fourth week of gestation. Assessment findings include urine protein +3, platelet count 95,000 mm3, and elevated AST and ALT levels. The nurse should suspect the development of which of the following? a. HELLP syndrome b. Placenta previa c. Hyperglycemia d. Abruptio placentae
A
A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? A) Early ambulation B) Prolonged labor C) Large fetus D) Use of anesthetics
A
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? a. Endometritis b. Endometriosis c. Salpingitis d. Pelvic thrombophlebitis
A
A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? a. Activity limited to bed rest b. Platelet infusion c. Immediate cesarean delivery d. Labor induction with oxytocin
A
A woman is not progressing in her labor, and her health care provider has decided that augmentation is needed. Based on common practice, the nurse anticipates the use of intravenous oxytocin or: a. Amniotomy b. Tocolytic agents c. Leopold's maneuver d. External version
A
A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure? A) "You'll need to stay in bed while you're having this procedure." B) "We'll give you an analgesic to help reduce the pain." C) "After the infusion, you'll be scheduled for a cesarean birth." D) "A suction cup is placed on your baby's head to help bring it out."
A
A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.
A
A woman who is 42 weeks pregnant comes to the clinic. Which of the following would be most important? A) Determining an accurate gestational age B) Asking her about the occurrence of contractions C) Checking for spontaneous rupture of membranes D) Measuring the height of the fundus
A
After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension? A) Mother had gestational hypertension during pregnancy. B) Client has a twin sister. C) Sister-in-law had gestational hypertension. D) This is the client's second pregnancy.
A
After teaching a group of students about the use of antiretroviral agents in pregnant women who are HIV-positive, the instructor determines that the teaching was successful when the group identifies which of the following as the underlying rationale? A) Reduction in viral loads in the blood B) Treatment of opportunistic infections C) Adjunct therapy to radiation and chemotherapy D) Can cure acute HIV/AIDS infections
A
Because a pregnant client's diabetes has been poorly controlled throughout her pregnancy, the nurse would be alert for which of the following in the neonate at birth? A) Macrosomia B) Hyperglycemia C) Low birthweight D) Hypobilirubinemia
A
For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? a. The membranes must rupture b. The fetus must be at 0 station c. The cervix must be dilated fully d. The patient must receive anesthesia
A
In a woman who is suspected of having a ruptured ectopic pregnancy, the nurse would expect to assess for which of the following as a priority? A) Hemorrhage B) Jaundice C) Edema D) Infection
A
The nurse interprets which of the following as evidence that a client is in the taking-in phase? A) Client states, "He has my eyes and nose." B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newborn.
A
The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle
A
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus
A
True labor is differentiated from false labor by: a. Dilation of the cervix b. Intensity of the contractions c. Duration of the contractions d. Amount of vaginal discharge
A
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because: A) These measurements may not change until after the blood loss is large B) The body's compensatory mechanisms activate and prevent any changes C) They relate more to change in condition than to the amount of blood lost D) Maternal anxiety adversely affects these vital signs
A
When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A) Early parent-infant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth
A
When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as the most common cause? A) Retained placental fragments B) Uterine atony C) Cervical or vaginal lacerations D) Uterine inversion
A
When teaching a class of pregnant women about the effects of substance abuse during pregnancy, which of the following would the nurse include? A) Low-birth weight infants B) Excessive weight gain C) Higher pain tolerance D) Longer gestational periods
A
Which of the following drugs is the antidote for magnesium toxicity? a. Calcium gluconate (Kalcinate) b. Hydralazine (Apresoline) c. Naloxone (Narcan) d. Rho (D) immune globulin (RhoGAM)
A
Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? A) Calcium gluconate B) Potassium chloride C) Ferrous sulfate D) Calcium carbonate
A
Causes of spontaneous abortion can include: a. Acute maternal infection b. Uterine atony c. Pregnancy-induced hypertension d. Hyperthyroidism
A .
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?
A normal test result
The nurse is caring for a postpartum woman whose baby was delivered by cesarean birth because of abruptio placentae. The nurse recognizes that she must be alert for which sign(s) and/or symptom(s)? (Select all that apply.) a. Bleeding gums b. Bleeding from injection sites c. Fatigue d. Epistaxis e. Dry skin f. Petechiae
A, B, D, F
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
Administer oxygen, 8 to 10 L/minute, via face mask
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?
Assess the baseline FHR
A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A) Expectations B) Transition to mastery C) Reality D) Taking-in
B
A postpartum client who is bottle feeding her newborn asks, "When should my period will return?" Which response by the nurse would be most appropriate? A) "It's difficult to say, but it will probably return in about 2 to 3 weeks." B) "It varies, but you can estimate it returning in about 7 to 9 weeks." C) "You won't have to worry about it returning for at least 3 months." D) "You don't have to worry about that now. It'll be quite a while."
B
A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c. Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure.
B
A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition? A) A low-lying placenta B) Fetopelvic disproportion C) Contraction ring D) Uterine bleeding
B
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus, expecting it to be: A) Two fingerbreadths above the umbilicus B) At the level of the umbilicus C) Two fingerbreadths below the umbilicus D) Four fingerbreadths below the umbilicus
B
A woman in active labor complains of feeling "dizzy and faint." When the nurse checks her blood pressure, she or he finds that the reading is lower than previous readings. Based on the nurse's inference, the first nursing action should be to: a. Lower the bed to the Trendelenburg position. b. Turn the patient to her left side. c. Recheck her blood pressure to verify accuracy of reading. d. Report this episode to the midwife or physician.
B
A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A) "You must have an infection, so let me get a urine specimen." B) "Your body is undergoing many changes that cause your bladder to fill quickly." C) "Your uterus is not contracting as quickly as it should." D) "The anesthesia that you received is wearing off and your bladder is working again."
B
A woman who is pregnant with twins is at risk for the development of which of the following? A) Oligohydramnios B) Preeclampsia C) Post-term labor D) Chorioamnionitis
B
A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A) Respiratory rate of 16 breaths per minute B) Diminished deep tendon reflexes C) Urine output of 45 mL/hour D) Alert level of consciousness
B
A woman with severe gestational hypertension is receiving a continuous intravenous infusion of magnesium sulfate. Which assessment finding would indicate the need for further intervention? a. Respiratory rate of 18/minute b. Absent deep tendon reflexes c. Urinary output of 60 mL/hour d. Blood pressure of 132/84 mm Hg
B
After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A) Presence of lochia serosa B) Frequent scant voidings C) Fundus firm, below umbilicus D) Milk filling in both breasts
B
After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A) "Holding a pillow against my incision will help me when I cough." B) "I'm going to have to wait a few days before I can start breast-feeding." C) "I guess the nurses will be getting me up and out of bed rather quickly." D) "I'll probably have a tube in my bladder for about 24 hours or so."
B
Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is: a. Anemia b. Decreased urine output c. Hyperreflexia d. Increased respiratory rate
B
The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which of the following would the nurse identify as the priority intervention? A) Position changes B) Pain relief measures C) Immediate cesarean birth D) Oxytocin administration
B
The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from: A) Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D) Becoming pregnant with an Rh-positive fetus
B
The nurse is assessing a newborn of a woman who is suspected of abusing alcohol. Which newborn finding would provide additional evidence to support this suspicion? A) Wide large eyes B) Thin upper lip C) Protruding jaw D) Elongated nose
B
The nurse is assisting with a breech delivery. What is the priority assessment? a. Fetal hip dislocations b. Cord prolapse c. Uterine rupture d. Fetal spinal injuries
B
The nurse would be alert for possible placental abruption during labor when assessment reveals which of the following? A) Macrosomia B) Gestational hypertension C) Gestational diabetes D) Low parity
B
The presenting part of the fetus becomes engaged in the pelvis when it reaches the level of the: a. Ischial tuberosities b. Ischial spines c. True pelvis d. False pelvis
B
The relationship of the presenting part to the ischial spines of the pelvis is called: a. Engagement b. Station c. Flexion d. Position
B
When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate? A) One who has undergone a previous myomectomy B) One who had a previous cesarean birth via a low transverse incision C) One who has a history of a contracted pelvis D) One who has a vertical incision from a previous cesarean birth
B
When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which of the following would be most appropriate? A) Monthly visits until 32 weeks, then bi-monthly visits B) Bi-monthly visits until 28 weeks, then weekly visits C) Monthly visits until 20 weeks, then bi-monthly visits D) Bi-monthly visits until 36 weeks, then weekly visits
B
Which factor would the nurse identify as being most important in helping to reduce the maternal/fetal/neonatal complications associated with pregnancy and diabetes? A) Stability of the woman's emotional and psychological status B) Degree of glycemic control achieved during the pregnancy C) Evaluation of retinopathy by an ophthalmologist D) Blood urea nitrogen level (BUN) within normal limits
B
Which of the following would be essential to implement to prevent late postpartum hemorrhage? A) Administering broad-spectrum antibiotics B) Inspecting the placenta after delivery for intactness C) Manually removing the placenta at delivery D) Applying pressure to the umbilical cord to remove the placenta
B
Which of the following would lead the nurse to suspect that a postpartum woman is having a problem? A) Elevated white blood cell count B) Acute decrease in hematocrit C) Increased levels of clotting factors D) Pulse rate of 60 beats/minute
B
Which of the following would the nurse interpret as being least indicative of paternal engrossment? A) Demonstrating pleasure when touching or holding the newborn B) Identifying imperfections in the newborn's appearance C) Being able to distinguish his newborn from others in the nursery D) Showing feelings of pride with the birth of the newborn
B
Which practice would be least effective in promoting bonding and attachment? A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth
B
Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A) "You have your daddy's eyes." B) "He looks like a frog to me." C) "Where did you get all that hair?" D) "He seems to sleep a lot."
B
When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR?
Between the umbilicus and the symphysis pubis
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. Which of the following would the nurse expect to include in the client's plan of care? A) Clear liquid diet B) Total parenteral nutrition C) Nothing by mouth D) Administration of labetalol
C
A group of postpartum women are discussing their experiences in labor and delivery. Which statement by a new mother best describes fetal presentation? a. "My baby's head was too large to descend." b. "The doctor said my baby was crosswise in my uterus." c. "My baby was breech, so I had to have a cesarean section." d. "My labor was long because the back of the baby's head was directed toward my backbone."
C
A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding? A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on
C
A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort? A) "Express some milk from your breasts every so often to relieve the distention." B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C) "Apply ice packs to your breasts to reduce the amount of milk being produced." D) "Take several warm showers daily to stimulate the milk let-down reflex."
C
A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which of the following in the newborn? A) Asphyxia B) Clavicular fracture C) Caput succedaneum D) Central nervous system injury
C
A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which of the following would the lead the nurse to suspect that the client is having an adverse effect associated with this drug? A) Gastrointestinal bleeding B) Blurred vision C) Tachycardia D) Sweating
C
A woman in her first trimester of pregnancy comes to the emergency department with moderate vaginal bleeding. She reports having had cramps earlier but has none now. This description is typical of a(n) _____ abortion. a. Missed b. Incomplete c. Threatened d. Recurrent
C
A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A) Sedatives B) Tocolytics C) Oxytocins D) Corticosteroids
C
A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also complains of acute abdominal pain that is continuous. Which of the following would the nurse suspect? A) Amniotic fluid embolism B) Shoulder dystocia C) Uterine rupture D) Umbilical cord prolapse
C
After examining the laboring woman, the physician tells her that her cervix showed some effacement. Later, the woman asks the nurse what "effacement" is. Effacement is best described as: a. Enlargement of the cervical os to permit the fetus to pass through b. Relaxation and stretching of perineal muscles c. Shortening and thinning of the cervix d. Loss of the mucous plug
C
After reviewing the Myrna's maternal history of magnesium sulfate during labor, which condition would nurse Richard anticipate as a potential problem in the neonate? a. Hypoglycemia b. Jitteriness c. Respiratory depression d. Tachycardia
C
After teaching a pregnant woman with iron deficiency anemia about her prescribed iron supplement, which statement indicates successful teaching? A) "I should take my iron with milk." B) " I should avoid drinking orange juice." C) "I need to eat foods high in fiber." D) "I'll call the doctor if my stool is black and tarry."
C
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following? A) Retained placental fragments B) Hypertension C) Thrombophlebitis D) Uterine subinvolution
C
The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A) "I'll basically follow the same diet that I was following before I became pregnant." B) "Because I need extra protein, I'll have to increase my intake of milk and meat." C) "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D) "I'll adjust my diet and insulin based on the results of my urine tests for glucose."
C
The nurse teaches a postpartum client how to do Kegel exercises for which reason? A) Reduce lochia B) Promote uterine involution C) Improve pelvic floor tone D) Alleviate perineal pain
C
The nurse would be alert for which of the following immediately after a woman with abruptio placentae gives birth? A) Severe uterine pain B) Board-like abdomen C) Appearance of petechiae D) Inversion of the uterus
C
To decrease the pain associated with an episiotomy immediately after birth, the nurse would: A) Offer warm blankets B) Encourage the woman to void C) Apply an ice pack to the site D) Offer a warm sitz bath
C
When assisting with an amniotomy, the nurse's first responsibility after the procedure is to check the: a. Maternal pulse b. Maternal blood pressure c. Fetal heart rate d. Fetal kick count
C
When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A) Greater than after a vaginal delivery B) About the same as after a vaginal delivery C) Less than after a vaginal delivery D) Saturated with clots and mucus
C
When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth, which is termed: A) Reciprocity B) Engrossment C) Bonding D) Attachment
C
When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) Deep red, fleshy-smelling lochia B) Voiding of 350 cc C) Heart rate of 120 beats/minute D) Profuse sweating
C
Which method would be most effective in evaluating the parents' understanding about their newborn's care? A) Demonstrate all infant care procedures B) Allow the parents to state the steps of the care C) Observe the parents performing the procedures D) Routinely assess the newborn for cleanliness
C
Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor
C
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse understands that which of the following must be present?
Cervical dilation of 2 cm or more
The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth?
Cesarean
A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next?
Check the fetal heart rate.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next?
Continue to monitor the FHR because this pattern is benign.
A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which of the following statements by the nurse would be most appropriate? A) "You'll probably have a cesarean birth to prevent exposing your newborn." B) "Antibodies cross the placenta and provide immunity to the newborn." C) "Wait until after the infant is born and then something can be done." D) "Antiretroviral medications are available to help reduce the risk of transmission."
D
A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A) "Your uterus is still shrinking in size; that's why you're feeling this pain." B) "Let me check your vaginal discharge just to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a tough workout." D) "The baby's sucking releases a hormone that causes the uterus to contract."
D
A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the patient's risk for: a. Endometriosis b. Female hypogonadism c. Premenstrual syndrome d. Tubal or ectopic pregnancy
D
A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like
D
A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which of the following findings would require immediate intervention? A) Fetal heart rate of 150 beats/minute B) Contractions every 2 minutes, lasting 45 seconds C) Uterine resting tone of 14 mm Hg D) Urine output of 20 mL/hour
D
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? a. Back b. Abdomen c. Fundus d. Perineum
D
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the following? A) An inverted nipple on the affected breast B) No breast milk in the affected breast C) An ecchymotic area on the affected breast D) Hardening of an area in the affected breast
D
A woman with diabetes is considering becoming pregnant. She asks the nurse whether she will be able to take oral hypoglycemics when she is pregnant. The nurse's response is based on the understanding that oral hypoglycemics: A) Can be used as long as they control serum glucose levels B) Can be taken until the degeneration of the placenta occurs C) Are usually suggested primarily for women who develop gestational diabetes D) Show promising results but more studies are needed to confirm their effectiveness
D
After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A) Supine B) Side-lying C) Sitting D) Knee-chest
D
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A) Marijuana B) Alcohol C) Heroin D) Cocaine
D
Assessment of a woman in labor who is experiencing hypertonic uterine dysfunction would reveal contractions that are: A) Well coordinated B) Poor in quality C) Rapidly occurring D) Erratic
D
At which time should the nurse screen a pregnant woman for group B streptococcus infection? A) 16 weeks' gestation B) 28 week' gestation C) 32 weeks' gestation D) 36 weeks' gestation
D
It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, when should the client receive RhoGAM? A) At 32 weeks' gestation and immediately before discharge B) 24 before delivery and 24 hours after delivery C) In the first trimester and within 2 hours of delivery D) At 28 weeks' gestation and again within 72 hours after delivery
D
Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition? a. Hemorrhage b. Hypertension c. Hypomagnesemia d. Seizure
D
The first action that should be taken when the umbilical cord prolapses is to: a. Administer oxygen by face mask at 8 to 10 L/minute. b. Have the woman get on her hands and knees. c. Prepare for a rapid vaginal delivery or cesarean. d. Position the woman so that her hips are higher than her head.
D
The nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth, identifying this as postpartum: A) Depression B) Psychosis C) Bipolar disorder D) Blues
D
The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A) Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D) Instructing her to apply ice packs to both breasts every other hour
D
When assessing a pregnant woman with heart disease throughout the antepartal period, the nurse would be especially alert for signs and symptoms of cardiac decompensation at which time? A) 16 to 20 weeks' gestation B) 20 to 24 weeks' gestation C) 24 to 28 week's gestation D) 28 to 32 week's gestation
D
Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A) Posterior position B) Firm C) Closed D) Shortened
D
Which medication would the nurse question if ordered to control a pregnant woman's asthma? A) Budesonide B) Albuterol C) Salmeterol D) Oral prednisone
D
Which of the following findings would the nurse interpret as suggesting a diagnosis of gestational trophoblastic disease? A) Elevated hCG levels, enlarged abdomen, quickening B) Vaginal bleeding, absence of FHR, decreased hPL levels C) Visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen D) Gestational hypertension, hyperemesis gravidarum, absence of FHR
D
Which one of the following findings would alert the nurse to the development of HELLP syndrome in a pregnant client? A) Hyperglycemia B) Elevated platelet count C) Disseminated intravascular coagulopathy (DIC) D) Elevated liver enzymes
D
Which statement is true in relation to abnormal fetal presentations? a. Meconium-stained amniotic fluid in a breech presentation always indicates fetal distress. b. Applying pressure to the mother's sacrum is especially helpful with a face or brow presentation. c. Having the mother assume a squatting position may facilitate the birth of the fetus in a breech presentation. d. When the fetus is in a persistent occiput posterior position, the mother may be assisted in getting on her hands and knees to help the fetus turn.
D
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
Deep tendons reflexes 2+
When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics?
Degree of thinning
Which of the following would most likely lead the nurse to suspect that a woman is experiencing postpartum psychosis?
Delirium
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that aburptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
Delivery of the fetus
The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?
Discontinue the infusion of oxytocin (Pitocin)
When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?
Every 30 minutes
The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?
Feel for the fetal buttocks or head while palpating the abdomen.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?
Fetal heart rate of 180 beats/minute
The nurse is preforming an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up?
Fetal heart rate of 180 beats/minute - normal range of the fetal heart rate is 160 to 170 beats/minute; near and at term, it changes from 110 to 160 beats/minute.
Which assessment finding following an amniotomy should be conducted first?
Fetal heart rate pattern - Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse.
Which of the following findings on a prenatal visit at 10 weeks might lead the nurse to suspect a hydatidiform mole?
Fundal height measurement of 18 cm
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
Hemorrhage
A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy?
Increased efficiency of contractions - Amniotomy (artificial rupture of the membreanes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow
When palpating the fundus during a contraction, the nurse notes that is feels like a chin. The nurse interprets this finding as indicating which type of contraction?
Moderate
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following?
Moderately strong contractions every 4 minutes, lasting about 1 minute
The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?
Monitoring the fetal heart rate ---- Dystocia is difficult labor that is prolonged or more painful than expected.
A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?
Naloxone
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action?
Notify the HCP
The 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 beats/minute. Which nursing action is most appropriate?
Notify the health care provider (HCP)
When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next?
Notify the health care provider.
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?
Obtain equipment for a manual pelvic examination
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?
Perform a vaginal examination every shift.
The nurse in a labor room is monitoring a client with a dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?
Persistent nonreassuring fetal heart rate
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?
Provide pain relief measures
Which of the following data on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
Recurrent pelvic infections
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following?
Respiratory depression
The nurse has been wroking with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?
Rest between contractions
Which of the following assessment findings in a postpartum client would be most alarming?
Sharp stabbing chest pain with shortness of breath
One of the frequent causes of bleeding during the first trimester of pregnancy is
Spontaneous abortion
A client in labor is transported to the delivery room and prepared for a cesarean delivery. Ater the client is transferred to the delivery room table, the nurse should place the client in which position?
Supine with a wedge under the right hip
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?
Support the mother in her reaction to the newborn infant
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
The cervix is dilated completely
The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?
The client has a history of cardiac disease
After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful?
The pelvic outlet is associated with the true pelvis.
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?
Upright
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspect diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?
Uterine tenderness - Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. - In abruptio placentae, acute abdominal pain is present.
Which of the following would indicate to the nurse that the placenta is separating?
Uterus becomes globular
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
Variable decelerations - Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus
Which of the following would be most appropriate when massaging a woman's fundus?
Wait until the uterus is firm to express clots.
