Maternity practice
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 A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.
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 All pregnant women should be screened for group B streptococcus infection at 35 to 37 weeks' gestation.
7. A client states, "I think my waters broke! I felt this gush of fluid between my legs." The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns: A) Yellow B) Olive green C) Pink D) Blue
D Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine paper that remains yellow to olive green suggests that the membranes are most likely intact.
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A) Supine B) Lithotomy C) Upright D) Knee-chest
C The use of any upright position helps to reduce the length of labor. Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy. The knee-chest position would assist in rotating the fetus in a posterior position.
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 As a result of the changes in blood volume and cardiac output after delivery, relative bradycardia may be noted. The woman's pulse rate may range from 50 to 70 beats per minute.
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 By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
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 HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or abruptio placentae.
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 A family history of gestational hypertension, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy.
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? A) "I will be sure to avoid getting pregnant for at least 1 year." B) "My intake of iron will have to be closely monitored for 6 months." C) "My blood pressure will continue to be increased for about 6 more months." D) "I won't use my birth control pills for at least a year or two."
A After evacuation of a hydatiform mole, long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for one year and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow-up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.
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 An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer's lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth.
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 Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS.
Which of the following is a priority when caring for a woman during the fourth stage of labor? A) Assessing the uterine fundus B) Offering fluids as indicated C) Encouraging the woman to void D) Assisting with perineal care
A During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.
A woman has just entered the second stage of labor. The nurse would focus care on which of the following? A) Encouraging the woman to push when she has a strong desire to do so B) Alleviating perineal discomfort with the application of ice packs C) Palpating the woman's fundus for position and firmness D) Completing the identification process of the newborn with the mother
A During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.
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 During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next? A) Continue to monitor the FHR because this pattern is benign. B) Perform a vaginal exam to assess cervical dilation and effacement. C) Stay with the client while reporting the finding to the physician. D) Administer oxygen after turning the client on her left side.
A Early decelerations are not indicative of fetal distress and do not require intervention. Therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal exam, report the finding to the physician, or administer oxygen.
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 Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.
Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A) Frank B) Full C) Complete D) Footling
A In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.
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 Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following? A) Respiratory depression B) Urinary retention C) Abdominal distention D) Hyperreflexia
A Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.
Which of the following would indicate to the nurse that the placenta is separating? A) Uterus becomes globular B) Fetal head at vaginal opening C) Umbilical cord shortens D) Mucous plug is expelled
A Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.
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 Poorly controlled diabetes during pregnancy can result in macrosomia due to hyperinsulinemia stimulated by fetal hyperglycemia. Typically the neonate is hypoglycemic due to the ongoing hyperinsulinemia that occurs after the placenta is removed. Infants of diabetic women typically are large and are at risk for hyperbilirubinemia due to excessive red blood cell breakdown.
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 Substance abuse during pregnancy is associated with low-birthweight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance abuse.
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 The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth? A) Cesarean B) Vaginal C) Forceps-assisted D) Vacuum extraction
A The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.
The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first? A) Feel for the fetal buttocks or head while palpating the abdomen. B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C) Palpate for the presenting part in the area just above the symphysis pubis. D) Determine flexion by pressing downward toward the symphysis pubis.
A The first maneuver involves feeling for the buttocks and head . Next the nurse palpates on which side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A) Latent phase of the first stage B) Active phase of the first stage C) Transition phase of the first stage D) Perineal phase of the second stage
A The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, and contractions occurring every 1 to 2 minutes lasting 60 to 90 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother.
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? A) Check the fetal heart rate. B) Perform a vaginal exam. C) Notify the physician immediately. D) Change the linen saver pad.
A When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The physician should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the physician has been notified.
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 With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage. Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy.
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 Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant.
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
Answer D Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome are not associated with progestin-only oral contraceptives.
Immediately after a delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding? a. Fetal body flexion or extension b. Maternal age, body frame, and weight c. Maternal and paternal ethnic backgrounds d. Maternal parity and gravidity
Answer A Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head a neonate. Molding is not influence by maternal age, body frame, weight, parity, or gravidity or by maternal and paternal ethnic backgrounds.
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
Answer A Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes.
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
Answer A Internal EFM can be applied only after the patient's membranes have ruptures, when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. although the patient may receive anesthesia, it is not required before application of an internal EFM device.
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
Answer A Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.
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
Answer D A bilateral pudental block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudental block anesthesia is adequate for episiotomy and its repair.
The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? a. Active phase b. Complete phase c. Latent phase d. Transitional phase
Answer D The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.
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
Answer: 2 Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
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
Answer: 2 Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
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: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion
Answer: 3 Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
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 Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.
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 Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.
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 During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus.
When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A) Extent of opening to its widest diameter B) Degree of thinning C) Passage of the mucous plug D) Fetal presenting part
B Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse understands that which of the following must be present? A) Intact membranes B) Cervical dilation of 2 cm or more C) Floating presenting fetal part D) A neonatologist to insert the electrode
B For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.
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 For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.
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 For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance.
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 Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.
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 Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.
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? A) Increased energy level with alternating strong and weak contractions B) Moderately strong contractions every 4 minutes, lasting about 1 minute C) Contractions noted in the front of abdomen that stop when she walks D) Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds
B Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.
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 Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities.
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 Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.
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 Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.
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 The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.
After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful? A) The bony pelvis plays a lesser role during labor than soft tissue. B) The pelvic outlet is associated with the true pelvis. C) The false pelvis lies below the imaginary linea terminalis. D) The false pelvis is the passageway through which the fetus travels.
B The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.
A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A) Platypelloid B) Gynecoid C) Android D) Anthropoid
B The most favorable pelvic shape for vaginal delivery is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.
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 The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.
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 Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state.
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 Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.
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 VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.
A woman telephones her health care provider and reports that her waters just broke. Which suggestion by the nurse would be most appropriate? A) "Call us back when you start having contractions." B) "Come to the clinic or emergency department for an evaluation." C) "Drink 3 to 4 glasses of water and lie down." D) "Come in as soon as you feel the urge to push."
B When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.
After describing continuous electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching? A) "This type of monitoring is the most accurate method for our baby." B) "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C) "This type of monitoring can only be used after my membranes rupture." D) "You'll be inserting a special electrode into my baby's scalp."
B With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.
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 Women with multiple gestations are at high risk for preeclampsia, preterm labor, polyhydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.
Which assessment finding would lead the nurse to suspect infection as the cause of a client's PROM? A) Yellow-green fluid B) Blue color on Nitrazine testing C) Ferning D) Foul odor
D A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would suggest meconium. A blue color on Nitrazine testing and ferning indicate the presence of amniotic fluid.
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? A) Intense B) Strong C) Moderate D) Mild
C A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong contraction feels like the forehead.
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? A) Every 4 hours B) Every 60 minutes C) Every 30 minutes D) Every 15 minutes
C During the active phase of labor, FHR is monitored every 30 minutes. The woman's temperature is typically assessed every 4 hours during the first stage of labor. Contractions and vital signs are monitored every 30 to 60 minutes during the latent phase; contractions are assessed every 15 minutes during the transition phase.
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? a) "I'm feeling contractions mostly in my back." b) "My contractions are about 6 minutes apart and regular." c) "The contractions slow down when I walk around." d) "If I try to talk to my partner during a contraction, I can't."
C False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.
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? A) Have the woman change her position. B) Administer oxygen. C) Notify the health care provider. D) Continue to monitor the pattern every 15 minutes.
C Fetal tachycardia as evidenced by a fetal heart rate greater than 160 bpm accompanied by a decrease in variability and late decelerations is an ominous sign indicating the need for prompt intervention. The health care provider should be notified immediately and then measures should be instituted such as having the woman lie on her side and administering oxygen. In this instance, monitoring should be continuous to detect any further changes and evaluate the effectiveness of interventions.
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 For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.
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 Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision, or sweating. Magnesium sulfate may cause sweating.
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 In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.
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? A) Use of oral contraceptives for 5 years B) Ovarian cyst 2 years ago C) Recurrent pelvic infections D) Heavy, irregular menses
C In the general population, most cases of ectopic pregnancy are the result of tubal scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy, irregular menses are not considered risk factors for ectopic pregnancy.
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 Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C-containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her doctor.
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 Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.
A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A) Butorphanol B) Fentanyl C) Naloxone D) Promethazine
C Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.
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 Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.
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? A) "Why are you crying?" B) "Will a pill help your pain?" C) "I'm sorry you lost your baby." D) "A baby still wasn't formed in your uterus."
C Telling the client that the nurse is sorry for the loss acknowledges the loss to the woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client that the baby wasn't formed is inappropriate and discounts any feelings or beliefs that the client has.
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A) +2 station B) 0 station C) -2 station D) Crowning
C The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.
A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A) Latent phase of the first stage of labor B) Active phase of the first stage of labor C) Transition phase of the first stage of labor D) Pelvic phase of the second stage of labor
C The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The active phase is characterized by moderate to strong contractions every 2 to 5 minutes, cervical dilation of 4 to 7 cm and effacement of 40% to 80%, with the mother becoming intense and inwardly focused. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.
When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR? A) Over the uterine fundus where contractions are most intense B) Above the umbilicus toward the right side of the diaphragm C) Between the umbilicus and the symphysis pubis D) Between the xiphoid process and umbilicus
C The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.
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 Typically, on admission, the woman with hyperemesis has oral food and fluids withheld to rest the gut and receives parenteral fluids to rehydrate and reduce the symptoms. Once the condition stabilizes, oral intake is gradually increased. Total parenteral nutrition may be used if the client's condition does not improve with several days of bed rest, gut rest, IV fluids, and antiemetics. Labetalol is an antihypertensive agent that may be used to treat gestational hypertension, not hyperemesis.
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 Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.
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 Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.
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? A) Urinary output of 20 mL per hour B) Respiratory rate of 10 breaths/minute C) Deep tendons reflexes 2+ D) Difficulty in arousing
C With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.
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 Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.
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 A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation.
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 Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of delivery should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Waiting until after the infant is born may be too late.
Which of the following findings on a prenatal visit at 10 weeks might lead the nurse to suspect a hydatidiform mole? A) Complaint of frequent mild nausea B) Blood pressure of 120/84 mm Hg C) History of bright red spotting 6 weeks ago D) Fundal height measurement of 18 cm
D Findings with a hydatidiform mole may include uterine size larger than expected. Mild nausea would be a normal finding at 10 weeks' gestation. Blood pressure of 120/84 would not be associated with hydatidiform mole and depending on the woman's baseline blood pressure may be within acceptable parameters for her. Bright red spotting might suggest a spontaneous abortion.
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 Gestational trophoblastic disease may be manifested by early development of preeclampsia (gestational hypertension), severe morning sickness due to high hCG levels, and absence of fetal heart rate or activity. There is no fetus, so quickening and evidence of a fetal skeleton would not be seen. The abdominal enlargement is greater than expected for pregnancy dates, but hCG, not hPL, levels are increased.
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 HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia is not a part of this syndrome. HELLP may increase the woman's risk for DIC.
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? A) "The warmth and buoyancy of the water has a nice relaxing effect." B) "I can stay in the bath for as long as I feel comfortable." C) "My cervix should be dilated more than 5 cm before I try using this method." D) "The temperature of the water should be at least 105 degrees F."
D Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105 degrees would be too warm. The warmth and buoyancy have a relaxing effect and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.
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 Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality and lack sufficient intensity to dilate and efface the cervix. Contractions of precipitous labor occur rapidly such that labor is completed in less than three hours.
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 If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.
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 Oral corticosteroids such as prednisone are not preferred in the treatment of asthma during pregnancy. However, they can be used to treat severe asthma attacks during pregnancy. Budesonide, albuterol, and salmeterol are recommended for use during pregnancy to control asthma.
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 Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minutes. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention.
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 Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.
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 Several studies have used glyburide an oral hypoglycemic agent with promising results. However, more intensive research is needed to establish the drug's safety and efficacy during pregnancy.
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 The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."
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 The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.
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 To prevent isoimmunization, the woman should receive RhoGAM at 28 weeks and again within 72 hours after delivery.
A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as: A) +4 B) +2 C) 0 D) -2
D When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.
