NUR 102 EXAM 6 (Weeks 11 & 12)
A nurse is caring for a client in active labor. When last examined 2 hrs ago, the client's cervix was 3cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states "my water broke." The monitor reveals a FHR of 80-85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position B. Apply pressure to the presenting part with her fingers C. Administer oxygen at 10L/min via face mask D. call for assitance
***ASK JULIE ATI page 113
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. record the findings 2. massage the fundus 3. notify the HCP 4. place patient in trendelenburg
3. If bleeding is excessive the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not control the bleeding. Option 4 should be avoided because it may interfere with cardiopulmonary function. Although the nurse would record the findings it is not the initial action.
On assessment of a postpartum client the nurse notes the uterus feels soft and boggy. The nurse should take which initial action? 1. document the finding 2. elevate clients legs 3. massage fundus until firm 4. push on uterus to assist in expressing clots
3. If the uterus is not contracted firmly, the intial intervention is to massage the fundus until it is firm and to express the clots that may have accumulated in the uterus. Option 2 doesn't assist in uterine atony. Option 1 should not be taken initially. Option 4 may cause uterine to invert and massive hemorrhage.
Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? 1. semirecumbent 2. sitting 3. squatting 4. side-lying
3. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet increasing pelvic outlet. Option 1 and 4 do not assist in increasing pelvic outlet. Sitting can help with fetal descent but it doesn't increase size of pelvic outlet
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. a primiparous client who delivered 4 hours ago 2. a multiparous client who delivered 6 hours ago 3. a mulitparous client who delivered a large baby after oxytocin induction 4. a primiparous client who delivered 6 hours ago and had an epidural
3. The causes of postpartum hemorrhage include uterine atony, laceration of the vagina, hematoma in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, over distention of the uterus from polyhydraminos, multiple gestation, a large neonate, infection, multiparity, dystocia, operative delivery (c-section/forceps), intrauterine manipulation. The multiparous client who delivered a large newborn after oxytocin induction has more risk factors than other clients.
Which description of the phases of the second stage of labor is accurate? 1. latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30-45 minutes 2. active phase: cervical dilation goes from 4-7cm 3. active pushing (descent) phase: significant increase in contraction, Ferguson reflux is activated, average duration varies 4. transition phase: woman "laboring down", fetal station is 0, duration is 15 minutes
3. The latent phase is the lull or laboring down period at the beginning of the second stage, lasting 10-30 minutes. The active phase is in the first stage of labor indicating cervical progression from 5-7cm. The transition phase is the final phase of the first stage of labor, contractions are strong and painful
A nures is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. increasing pulse and decreasing BP B. dizziness and increasing RR C. cool, clammy skin, and pale mucous membranes D. AMS and LOC
A. Options B and C are not early indications and option D is a late manifestation of decreased blood volume.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assess the client for which classic signs of preeclampsia? Select all the apply 1. proteinuria 2. hypertension 3. low grade fever 4. generalized edema 5. increased pulse rate 6. increased respiratory rate
1,2. The two classic signs of preeclampsia are hypertension and proteinuria. Options 3,5,6 are not associated with preeclampsia. Generalized edema may occur, nut is no longer included as a classic sign of preeclampsia because it can occur in many conditions.
On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6cm, -1. What is a correct inerpretation of the data? 1. the fetal presenting part is 1cm above the ischial spines 2. effacement is 4cm from completion 3. dilation is 50% completed 4. the fetus has achieved passage through the ischial spines
1. Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages. Progress of dilation is referred to by centimeters. Passage through the ischial spines with internal rotation would be indicated as +1
The nurse in the post partum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and plans to monitor the client for which risk associated with placenta previa. 1. infection 2. hemorrhage 3. chronic HTN 4. dissemenated intravascular coagulation (DIC)
2. In placenta previa the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus and this site is more prone to bleeding. Options 1,3,4 are not risk related to placenta previa.
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? 1. uterine tone 2. BP 3. amount of lochia 4. deep tendon reflexes
2. Methylergonovine contracts the uterus to prevent or control postpartum hemorrhage. Methelyergonovine causes continous uterine contractions and may increase the blood pressure. A priority assessment is to check BP and the HCP should be notified if hypertension is present. Options 1,3,4 may be components of the postpartum assessment but BP is related specifically to the administration of this med.
What is the purpose of Methotrexate?
A folic acid antagonist to inhibit cell division in the developing embryo in an ectopic pregnancy
What is HELLP syndrome?
A laboratory diagnosis for severe preeclampsia characterized by Hemolysis, Elevated Liver enzyme levels and Low Platelet count
A nurse is discussing risk factors for UTIs with newly licensed nurses. Which of the following conditions should the nurse include in the teaching? SATA. A. Epidural anesthesia B. urinary bladder catherization C. frequent pelvic examinations D. history of UTIs E. vaginal birth
A,B,C,D are all risk factors. Cesearean birth, not vaginal, would place client at risk. **
A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? SATA. A. gonorrhea B. chlamydia C. HIV D. Group B streptococcus beta-hemolytic E. TORCH infection
A,B,C,D. Erythromycin is administered to the infant immediately following delivery to prevent gonorrhea and chlamydia. Retrovir is prescribed to a client in labor who is HIV+. Penicillin G or ampicillin is prescribed to treat +GBS. TORCH infections can be treated during pregnancy depending upon infection.
A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? SATA. A. joint pain B. malaise C. rash D. urinary frequency E. tender lymph nodes
A,B,C,E. TORCH infections are flu-like symptoms. Option D is not a clinical finding associated with TORCH infection.
A nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factors of this conditions? SATA. A. UTI B. multifetal pregnancy C. oligohydramnios D. diabetes mellitus E. uterine abnormalities
A,B,D,E are all risk factors for preterm labor. Hydramnios is a risk factor for preterm labor, not oligohydramnios.
A nurse is caring for a client who is at 14 weeks of gestation nd has hyperemesis gradvidarum. The nurse should identify that which of the following are risk factors for the client? SATA. A. obesity B. multifetal pregnancy C. maternal age greater than 40 D. migraine headache E. oligohydramnios
A,B,D. Maternal age less than 30 is a risk factor for hyperemesis gradvidarum. Option E is not a risk factor.
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,110g. Which of the following are expected findings in this newborn? SATA. A. lanugo B. long nails C. weak grasp reflex D. translucent skin E. plump face
A,C,D. Option B is seen in preterm newborns. Option E would be seen in a newborn who is macrosomic.
A nurse is caring for a client who has a prescription for mag sulfate. The nurse should recognize that which of the following are contraindications for the use of this medication? SATA. A. fetal distress B. preterm labor C. vaginal bleeding D. cervical dilation greater than 6cm E. severe gestational hypertension
A,C,D. Options B and E are indications for mag sulfate.
A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis. Which of the following clinical findings should the nurse expect? SATA. A. calf tenderness to palpation B. mottling of the affected extremity C. elevated temp D. area of warmth E. report of nausea
A,C,D. Options B and E are not expected findings of DVT
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? SATA. A. precipitous delivery B. obesity C. inversion of the uterus D. oligohydramnios E. retained placental fragments
A,C,E.
A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindication? SATA. A. hypospadias B. hydrocele C. family history of hemophilia D. hyperbilirubinemia E. epispadias
A,C,E. Options B and D are not contraindicated
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? SATA. A. episotomy B. oxytocin infusion C. forceps D. cesarean birth E. internal fetal monitoring
A,C,E. These options are contraindicated should be avoided for a client who is HIV-positive D/T risk of maternal blood exposure. Options B and D are not contraindicated.
A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. WHich of the following types of medicaitons should the nurse anticipate the provider will prescribe? A. Betamethasone B. indomethacin C. nifedipine D. methylergonovine
A. Betamethasone is given to promote lung maturity if delivery is anticipated. Options B and C are prescribed for a client in preterm labor. Option D is given is client is experiencing postpartum hemorrhage.
A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse anticipate the provider will prescribe? A. ceftriaxone B. fluconazole C. metronidazole D. zidovudine
A. Ceftriaxone IM or doxycycline orally for 7 days is prescribed for the treatment of gonorrhea. Fluconazole is used to treat candidiasis. Metronidazole is used to treat bacterial vaginosis and trichomoniasis. Zidovudine is used to treat HIV/AIDS
A nurse is caring for a client who has DIC. Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. preeclampsia B. thrombophlebitis C. placenta previa D. hyperemesis gravidarum
A. DIC can occur secondary in a client who has preeclampsia. Options B,C,D are not risk factors for DIC.
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. hands and knees B. lithotomy C. trendelenburg D. supine with a rolled towel under one hip
A. Having the client assume a position on her hands and knees can help the fetus rotate from a posterior to an anterior position. The lithotomy position is when the client lies on her back with her knees elevated and does not facilitate labor progression. Options 3 and 4 do not assist in rotation of the fetus.
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. I should stay on the diabetic diet 2. I should perform glucose monitoring at home 3. I should avoid exercise because of the negative effects on insulin production 4. I should be aware of any infection and report signs of infection immediately to my HCP
3. Exercise is safe for a client with GDM and is helpful in lowering the blood glucose level. Options 1,2,4 are statements of understanding by the client.
Which assessment following an amniotomy should be conducted first? 1. cervical dilation 2. bladder distention 3. FHR pattern 4. maternal blood pressure
3. FHR is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Options 2 and 4 would not be the first thing to check following an amniotmy.
A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A. a client who experienced a precipitous labor less than 3hrs in duration B. a client who had premature ROM and prolonged labor C. a client who delivered a LGA infant D. a client who had a boggy uterus
B. Premature ROM with prolonged labor poses the greatest risk for developing postpartum infection because the birth canal was open. Option A places the client at risk for trauma. Options C and D places the client at risk for infection but Option B poses the greatest risk.
A nurse is caring for a newborn immediately following a circ using a Gomco procedure. Which of the following actions should the nurse implement? A. apply Gelfoam powder to the site B. place the newborn in the prone position C. apply petroleum gauze to the site D. avoid changing the diaper until the first voiding
C. Petroleum is applied to prevent skin edges from sticking to the diaper. Gelfoam powder is used to control bleeding when there is a risk for hemorrhage. Newborns should not be placed in prone position. Diapers are changed frequently to inspect the site.
A nurse is caring for a client who i at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A. intrauterine growth restriction B. hyperglycemia C. meconium asipration D. polyhramnios
C. Postterm neonates are at risk for aspiration of meconium. Intrauterine growth restrictions occurs earlier in the pregnancy. A postterm neonate is at risk for hypoglycemia. Postterm pregnancies result in oligohyramnios.
A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. his circ will heal within a couple of days B. i should remove the yellow mucus that will form C. I will clean his penis with each diaper change D. I will give him a tub bath within a couple of days
C. The circ will heal within a couple of weeks. Yellow mucus should remain in place as part of the healing process. Tub bath should not be given until circ is healed.
A nurse is caring for a client who has suspected hyperemesis graviadarum and is reviewing the client's lab reports. Which of the following is a manifestation of the condition? A. Hgb 12.2g/dL B. urine ketones present C. alanine amniotransferase 20IU/L D. serum glucose 114mg/dL
B. The presence of ketones in the urine is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gradvidarum. Altered Hct is manifestation of hyperemesis gravidarum D/T hemoconcentration that occurs with dehydration. Liver enzymes are elevated in a client who has hyperemesis gradivarum. Decreased serum glucose is anticipated finding.
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued N/V and scant, prune colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? A. hyperemesis gravidarum B. threatened abortion C. hydatidiform mole D. preterm labor
C. A client who has hydatidiform mole exhibits increased fundal height that is inconsistent with the week of gestation, and excessive N/V D/T elevated hCG levels. Scant, dark discharge occurs in the second trimester. Opion A would present with weight loss and signs of dehydration. Option B would present in the first trimester and report spotting to moderate bleeding with no enlarged uterus. Option D would present prior to 37 weeks of gestation and is accompanied by pink stained vaginal discharge and uterine contractions that become more regular.
A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A. cover the cord with small gauze square B. trickle clean water over the cord with each diaper change C. apply hydrogen peroxide to the cord twice a day D. Keep the diaper folded below the cord
D - prevents urine from penetrating cord site. Option A prevents cord from drying. Water should not be applied to the cord, it should be kept clean and dry.
A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition? A. no altereation in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. serum progesterone greater than the expected reference range D. report of severe shoulder pain
D. A client's report of severe shoulder pain is a finding associated with a ruptured ectopic pregnancy D/T the presence of blood in the abdominal cavity, which irritates the diaphragm and phrenic nerve.
A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. precipitous labor B. premature ROM C. postmaturity syndrome D. prolapsed umbilical cord
D. A prolapsed umbilical cord is a potential complication for a fetus in the breech presentation. Dystocia would be more likely than precipitous labor. Breech presentation is not associated with ROM or postmaturity syndrome
A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. calcium gluconate B. indomethacin C. nifedipine D. betamethasone
D. Betamethasone is a glucocorticoid given to clients in preterm labor to hasten surfactant production. Calcium gluconate is administered as an antidote for mag sulfate toxicity. Indomethacin is an NSAID used to suppress preterm labor by blocking prostaglandin production. Nifedipine is a CCB used to suppress uterine contractions
A nurse is caring for a client who is receiving IV Mag Sulfate. Which of the following medications should the nurse anticipate administering if mag sulfate toxicity is suspected? A. nifedipine B. pyridoxine C. ferrous sulfate D. calcium gluconate
D. Calcium gluconate is the antidote for mag sulfate. Nifedipine an antihypertensive medication used with gestational hypertension. Pyridoxine is a vitamin supplement prescribed for clients who have hyperemesis gradvidarum. Ferrous sulfate is a med used in treatment of iron deficiency anemia.
A nurse is reviewing discharge teaching with a client who has premature ROM at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? A. use a condom with sexual intercourse B. avoid bubble bah solution when taking a tub bath C. wipe from the back to front when performing perineal hygiene D. keep a daily record of fetal kick counts
D. Client with ROM should haven nothing inserted vaginally. Baths should be avoided and wiping should be from front to back.
Abdominal pain, vaginal spotting to bleeding that is dark red or brown are signs of what?
Ectopic pregnancy
What are the two signs of preeclampsia?
Hypertension and proteinuria usually occurring after the 20th week of gestation
What are the five Ps that affect the process of labor and birth?
Passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, psychologic response
Referred shoulder pain in someone who has a suspected ectopic pregnancy is a sign of what?
Ruptured ectopic pregnancy
The nurse is monitoring a client in preterm labor who is receiving IV mag sulfate. The nurse should monitor for which adverse effects of the med? SATA 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed resperations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes
1, 4, 5. Mag sulfate adverse effects include flushing, depressed resp, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum mag levels.
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? SATA. 1. Wear a supportive bra 2. rest during the acute phase. 3. maintain a fluid intake of at least 3000mL/day 4. continue to breast feed if the breasts are not too sore 5. take the prescribed antibiotics until the soreness subsides 6. avoid decompression of the breasts by breast feeding or breast pump
1,2,3,4. Antibiotics are taken for the prescribed amount of time. Continued decompression is important to empty the breast and prevent the formation of an abscess.
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for the complication. Select all that apply. 1. age of 54 2. BMI of 28 3. previous difficulty with fertility 4. administration of Oxytocin for induction 5. K level of 3.6mEq/L
1,2,3. Risk factors that increase a woman's risk for dysfunctional labor includes the following: advanced maternal age, obesity, electrolyte imbalances, previous difficult fertility, uterine over stimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of analgesic early in labor, use of epidural anesthesia. Option 4 is not a risk factor, and option 5 is within normal ranges.
Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1. a return of urinary frequency as a result of increased bladder pressure 2. persistent low backache from relaxed pelvic joints 3. stronger and more frequent uterine (Braxton Hicks) contractions 4. a decline in energy as the body stores up for labor 5. uterus sinks downward and forward in first time pregnancies
1,2. After lightening a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache as a result of relaxation of pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in frequency and strength. A surge of energy is common in days preceding labor. In first-time pregnancies the uterus sinks downward and forwards about 2 weeks before term. (MCNC chapter 13 review)
The client nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting HIV? Select all that apply. 1. the client has a history of intravenous drug use 2. the client has a significant other who is heterosexual 3. the client has a history of sexually transmitted infections 4. the client has had one sexual partner for the past 10 years 5. the client has a previous history of gestational diabetes mellitus
1,3. HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage of fetus an infected woman to her fetus.
The nurse asks the nursing student to describe the procedure to administer erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the medication? 1. I will flush the eyes after administration of the ointment 2. I will clean the newborns eyes before instilling ointment 3. I need to administer the eye ointment within 1 hour of delivery 4. I will instill the eye ointment into the newborns conjunctival sacs
1.
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 FHR between contractions is 100bpm. Which nursing action is most appropriate? 1. Notify the HCP 2. Continue monitoring FHR 3. Encourage the client to continue pushing with each contraction 4. Instruct the client's coach to continue to encourage breathing techniques
1. A normal FHR is 110 - 160 bpm and the FHR should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management so HCP needs to be notified.
The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. We want to attend a support group 2. we never want to try to have a baby again 3. we are going to try to adopt a child immediately 4. we are okay, and we are going to try to have another baby immediately
1. A support group can help the parents to work through their pain by nonjudgmental sharing of feelings. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis on these findings the nurse should prepare the client which anticipated prescription? 1. delivery of the fetus 2. strict I&O 3. complete bed rest for remainder of pregnancy 4. the need for weekly monitoring of coagulation studies until time of delivery
1. 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. The goal of mgmt in abruptio placentae is to contorl the hemorrhage and deliver the fetus as soon as possible. Delivery is treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary options 2,3,4 are incorrect.
On review of a fetal monitor tracing, the nurse notes that for several contractions, the FHR decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: 1. describe the finding in the nurse's notes 2. reposition the woman onto her side 3. call the physician for instructions 4. administer oxygen at 8-10L/min with a tight face mask
1. An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix. Options 2,3,4 would be implemented when non-reassuring or ominous changes are noted.
The nurse is monitoring a postpartum client who recieved epidural anesthesia during delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. change in V/S 2. signs of heavy bruising 3. complaints of intense pain 4. complaints of a tearing sensation
1. Because the client has had epidural anesthesia and is anesthesized, she cannot feel pain, pressure, or a tearing sensation. Changes in V/S indicate hypovolemia in an anesthesized client with a hematoma. Option 2 may be seen but V/S changes indicate hematoma caused by blood collection in the perineal tissues.
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1. provide pain relief measures 2. prepare the client for an amniotomy 3. promote ambulation every 30 minutes 4. monitor oxytocin infusion closely
1. Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Mgmt of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Options 2 and 4 are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic contractions would be encouraged to rest, not ambulate frequently.
Fetal well-being during labor is assessed by: 1. the response of FHR to uterine contractions 2. maternal pain control 3. accelerations in the FHR 4. a FHR greater than 110bpm
1. In general, reassuring FHR patterns are characterized by a FHR baseline of 110-160bpm with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Option 2 is not a measure to determine fetal well-being in labor. Options 3 and 4 do not contain all the components to determine fetal well being during labor
A nurse in the labor and delivery unit is caring for a client in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140bpm. Contractions are occurring every 8 minutes and 30-40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is the client experiencing? 1. first stage, latent phase 2. first stage, active phase 3. first stage, transition phase 4. second stage of labor
1. In stage 1, latent phase, the cervix dilates from 0 to 3cm, and contraction duration ranges from 30-45 seconds. In stage 1, active phase, the cervix dilates from 4-7cm, and contraction duration ranges from 40-70 seconds. In stage 1, transition phase, the cervix dilates from 8-10cm, and contraction duration ranges from 45-90 seconds. The second stage of labor consists of expulsion of the fetus
The 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? 1. I will need to increase my insulin dosage during the first 3 months of pregnancy 2. My insulin dose will likely need to be increased during the second and third trimesters 3. Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy 4. My insulin needs should return to prepregnant levels within 7-10 days after birth if I am bottle-feeding
1. Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2,3,4 are accurate and signify that the client understands control of her diabetes during pregnancy.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. administer oxygen via face mask 2. place the mother in a supine position 3. increase the rate of the oxytocin intravenous infusion 4. document the findings and continue to monitor the fetal patterns
1. Late decelerations are due to uteroplacental insufficiency and occur because of the decreased blood flow and oxygen to the fetus during uterine contractions. Supine position is avoided because it decreased uterine blood flow to the fetus. IV Oxytocin infusion is discontinued when a late deceleration is noted.
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: 1. change in position 2. oxytocin administration 3. regional anesthesia 4. intravenous analgesic
1. Maternal supine hypotension syndrome reduces venous return to the woman's heart, as well as cardiac output leading to decreased blood pressure. Changing positions and avoiding supine position can help increase cardiac output. Options 2,3,4 will reduce maternal cardiac output
An opioid analgesic is adminstered to a client in labor. The nurse assigned to client ensures which medication is readily available should respiratory depression occur? 1. naloxone 2. morphine sulfate 3. betamethasone 4. hydromorphone hydrochloride
1. Naloxone is an opioid antagonist, which rverses the effects of opioids and is given for respiratory depression. Options 1 and 4 are opioids and option 3 is a corticosteroid administered to enhance fetal lung maturity.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. trendelenburg's position with the legs in stirrups 3. prone position with the legs separated and elevated 4. semi-fowler's position with a pillow between the knees
1. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus
When using intermittent auscultation to assess uterine activity, nurses should be aware that: 1. the examiner's hand should be placed over the fundus before, during, and after contractions 2. the frequency and duration of contractions are measured in seconds for consistency 3. contraction intensity is given a judgment number of 1-7 by the nurse and client together 4. the resting tone between contractions is described as either placid or turbulent
1. The assessment is done by palpation (duration, frequency, intensity, and resting tone must be assessed). The duration of contractions is measured in seconds, the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate or strong. The resting tone is usually characterized as soft or relaxed.
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: 1. encouraging the woman to try various upright positions, including squatting and standing 2. telling the woman to start pushing as soon as her cervix is dilated 3. continuing an epidural anesthetic so that pain is reduced and the women can relax 4. coaching the woman to use sustained 10-15 second, closed-glottis bearing down efforts with each contraction
1. Upright positions and squatting may enhance the progress of fetal descent. Complete cervical dilation is necessary but it is only one factor (if fetal head is still in higher pelvic station, more time is needed for fetal descent before pushing). Epidural may mask the sensations and muscle control needed for a woman to push. Closed-glottic breathing may trigger the Valsalva maneuver (increases intrathoracic and cardiovascular pressure, reducing cardiac output) in addition holding breath for longer than 5-7 seconds diminishes the perfusion of oxygen across the placenta
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? 1. What can I do for you? 2. Now you have an angel in heaven 3. Don't worry, there is nothing you could have done to prevent this from happening 4. We will see to it that you have an early discharge so that you don't have to be reminded of this experience
1. When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their HCP or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication while considering cultural and religious practices and beliefs.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. you will need to bottle-feed your newborn 2. you will need to feed your newborn by nasogastric tube feeding 3. you will be able to breast-feed for 6 months and then will need to switch to bottle feeding 4. you will be able to breast-feed for 9 months and then will need to switch to bottle-feeding
1. perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventative measure may be prescribed 2. routine administration of subcut heparin may be prescribed 3. an overbed lift may be necessary if the client requires a cesarean section 4. Less frequent cleaning of a cesaren incision, if present, may be prescribed 5. thromboembolism stockings or sequential compression devices may be prescribed
2,3,5. The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Frequent ambulation would be offered, not bed rest. More frequent cleaning is needed to prevent infection D/T increased abdominal fat.
A pregnant client is receiving mag sulfate for the mgmt of preeclampsia. The nurse determines the client is experiencing toxicity from the medication if which findings are noted on assessment? SATA. 1. proteinuria of 3+ 2. RR of 10bpm 3. presence of deep tendon reflexes 4. urine output of 20mL/hour 5. serum mag level of 4mEq/L
2,4. Signs of mag sulfate toxicity relate to the CNS depressant effects, including respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal and maternal HR and BP. RR below 12bpm is a sign of toxicity, urine output should be at least 25-30mL/hour. Option 1 is an expected finding of a client with preeclampsia. Therapeutic serum mag levels are 4-7.5mEq/L.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the HCP? 1. Hemoglobin of 11 g/dL 2. FHR of 180bpm 3. Maternal pulse rate of 85bpm 4. WBC count 12,000
2. A normal FHR is 110-160bpm when almost to term. A FHR of 180bpm could indicate fetal distress. By full term, a normal maternal hgb range is 11-13g/dL (this is due to the hemodilution caused by an increase in plasma volume during pregnancy). WBC counts in normal pregnancy is 11,000-15,000. During immediate postpartum period WBC count can reach 25,000-30,000 due to increased leukocytosis that occurs during delivery.
Which test is performed to determine if membranes are ruptured? 1. urine analysis 2. fern test 3. leopold maneuvers 4. artificial rupture of membranes
2. A sterile speculum examination, a Nitrazine (pH), and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be preformed on admission to labor and delivery to identify presence of glucose and protein. Leopold maneuvers is used to identify fetal lie, presenting part, and attitude.
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. soft abdomen 2. uterine tenderness 3. absence of abdominal pain 4. painless, bright red vaginal bleeding
2. Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before th fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless ,bright red vaginal bleeding are signs of placenta previa.
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? 1. Identify the types of acclerations 2. assess the baseline FHR 3. determine the intensity of the contractions 4. determine the frequency of the contractions
2. Assessing the baseline FHR is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor.
A client in preterm labor, 31 weeks, who is dilated to 4cm has been started on mag sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. nalbuphine 2. betamethasone 3. Rh immune globulin 4. dinoprostone vaginal insert
2. Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28-32 weeks of gestation if the labor can be inhibited for 48 hours. Option 1 is an opioid analgesic. Option 3 is given to Rh negative clients to prevent sensitization. Option 4 is a prostaglandin given to ripen and soften the cervix and to stimulate contractions
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. providing sitz baths 2. encouraging fluid intake 3. placing ice on the perineum 4. monitoring H&H
2. Cystitis is an infection of the bladder. The client should consume 3000mL/day if not contraindicated. Option 1 and 3 would appropriate interventions for perineal discomfort. Option 4 would be monitored with hemorrhage.
The nurse is monitoring a client in the immediate post partum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. temp of 100.4F 2. increase in pulse rate from 88 to 102bpm 3. a BP change of 130/88 to 124/80 4. increase in RR from 18 - 22 breaths per minute
2. During the fourth stage of labor the maternal BP, Pulse, and RR should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of blood loss because the heart pumps faster to compensate for reduced blood volume. Option 1 is normal. Option 3 is not an early sign. Option 4 is normal because a slight increase in RR is expected during this period.
The nurse has created 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? 1. providing comfort measures 2. monitoring FHR 3. changing the client's position frequently 4. keeping SO informed on progress of labor
2. Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the FHR although options 1,3,4 are included in plan of care, fetal status is priority.
Which characteristic is associated with false labor contractions? 1. lead to cervical change. 2. decrease in intensity with ambulation 3. regular pattern of frequency established 4. progressive in terms of intensity and duration
2. False labor contractions decrease with activity (true labor contractions are enhanced or stimulated with activity). Options 1,3,4 are signs of true labor
When assessing a FHR tracing, the nurse notes a decrease in the baseline rate from 155-110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: 1. maternal hyperthyroidism 2. initiation of epidural anesthesia that resulted in maternal hypotension 3. maternal infection accompanied by fever 4. alteration in maternal position from semirecumbent to lateral
2. Fetal bradycardia is the pattern described and results from hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during administration to maintain adequate cardiac output and BP. Options 1 and 3 would cause fetal tachycardia. Option 4 should result in a reassuring FHR pattern.
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instructions should the nurse include in the client's teaching plan? 1. therapeutic abortion is required 2. isoniazid plus rifampin will be required for 9 months 3. she will have to stay at home until treatment is completed 4. medication will not be started until after delivery of the fetus
2. More than 1 medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (Vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.
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? 1. prepare the client for an ultrasound 2. obtain equipment for a manual pelvic examination 3. prepare to draw a H&H 4. obtain equipment for external fetal monitoring
2. Placenta previa is an imporoperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. A diagnosis of placenta previa is made by ultrasound. The H&H levels are monitored and external FHR monitoring is initiated.
The nurse is preforming an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is a risk for preterm labor? 1. the client is 35 y/o primigravida 2. the client has a history of cardiac disease 3. the client Hgb is 13.5g/dL 4. the client is a 20y/o primigravida of average weight and height
2. Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor including a history of medical conditions, present and past OB problems, social and environmental factors and substance abuse. The other risk factors include multifetal pregnancy which contributes to over distention of the uterus, anemia which decreases oxygen supply to the uterus, and age younger than 18 years or first pregnancy at age over 40 years.
The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the med through which route? 1. intradermal 2. intratracheal 3. subcut 4. intramuscular
2. Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Options 1,3,4 are not routes of administration.
A nurse in labor and delivery unit is completing an admission assessment for a client who is at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing? 1. cord prolapse 2. infection 3. postpartum hemmorrhage 4. hydramnios
2. Rupture of membranes for longer than 24 hours prior to delivery increases the risk that infectious organisms will enter the vagina. Although cord prolapse is a risk with rupture of membranes, it occurs when the fluid rushes out, not trickles. This client is more likely to have oligohydramnios (insufficient amniotic fluid) rather than hydramnios (excess amniotic fluid)
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1. I will watch for evidence of the passage of tissue 2. I will maintain strict bed rest throughout the remainder of the pregnancy 3. I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad 4. I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding
2. Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. Options 1,2,4 are all correct answers
The nurse has been working 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? 1. ambulation 2. rest between contractions 3. change in positions frequently 4. consume oral food and fluids
2. The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion is also enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1.5-2 minutes. The nurse's immediate action would be to: 1. change the woman's position 2. stop the Pitocin infusion 3. elevate the woman's legs 4. administer oxygen via a tight mask at 8-10L/min
2. The immediate action would be to stop the Pitocin infusion since it stimulates the uterus to contract. The woman is already in an appropriate position for uteroplacental perfusion. Elevation of legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 -3 minutes, with a duration of 60 seconds. An internal FHR monitor is in place. The baseline FHR has been between 120-122bpm for the past hour. What is the priority nursing action? 1. Notify the HCP 2. Discontinue the infusion of oxytocin 3. Place oxygen on at 8 - 10 L/min via face mask 4. Contact the client's primary support person(s) if not currently present
2. The priority nursing action is to stop the infusion of oxytocin which can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability.
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of an umbilical protruding from the vagina. What is first nursing action with this finding? 1. gently push the cord into the vagina 2. place client in trendelenburg position 3. find the closest telephone and page HCP STAT 4. call the delivery room to notify staff client will be transported immediately
2. When cord prolapse occurs prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift fetal presenting part toward the diaphragm. If the cord is protruding from the vagina, no attempt should be made to replace it because trauma and reduced blood flow can occur to the cord. Options 3 and 4 are not the first action to take.
The nurse is monitoring a client who is receiving Oxytocin to induce labor. Which assessment finding should cause the nurse to immediately discontinue the infusion? SATA. 1. Fatigue 2. drowsiness 3. uterine hyperstimulation 4. late decels of FHR 5. early decels of FHR
3,4. Options 1,2,5 are expected findings of the administration of Oxytocin. Option 4 is a sign of fetal distress, and option 3 is adverse effect.
A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The HCP prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent FHR monitoring to detect the presence of a prolapsed cord
3,5. Amniotomy (artificial rupture of the membranes) 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. Rupturing of the membranes allows the fetal head to contact the cervix more directly and more increase the efficiency of contractions. The FHR needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.
The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all the apply. 1. a primigravida with mild preeclampsia 2. a primigravida who delivered a 10lb infant 3 hours ago 3. a gradiva 2 who has just been diagnosed with dead fetus syndrome 4. a gravida IV who delivered 8 hours ago and has lost 500ml of blood 5. a primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia
3,5. In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC;a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however a loss of 500mL is not considered hemorrhage.
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. the contractions are regular 2. the membranes have ruptured 3. the cervix is dilated completely 4. the client beings to expel clear vaginal fluid 5. the spontaneous urge to push is initiated from perineal pressure
3,5. The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from pernieal pressure. Options 1,2,4 occur in stage 1.
A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough. I can't do this anymore. I want to go home right now." Which of the following stages of labor is the client experiencing? 1. second stage 2. fourth stage 3. transition stage 4. latent phase
3. The transition phase of labor occurs when the client becomes irritable, feels rectal pressure, and becomes nauseous. The second stage of labor occurs with the expulsion of the fetus. The fourth stage of labor is the recovery period following the delivery of the placenta. The latent phase of labor occurs in stage one and coincides with mild contractions, relaxed, talkative client who is eager for labor to progress
A nurse caring for a woman in labor understands that moderate variability of the FHR might be caused by: 1. narcotics 2. barbiturates 3. methamphetamines 4. tranquilizers
3. The use of illicit drugs such as cocaine or methamphetamines might cause moderate variability. Narcotics and tranquilizers are a possible cause of absent or minimal variability in FHR. Barbiturates result in significant decrease in variability as these are known to cross the placental boarder
The nurse's priority action when observing early deceleration indicating expected head compression during contraction is to: 1. notify the HCP 2. Assist with vaginal examination to assess for cord prolapse 3. change maternal position 4. assist with amnioinfusion
3. The usual priority is as follows - 1. change maternal position (side to side, knees to chest). 2. discontinue oxytocin if infusing. 3. administer oxygen at 8-10L/min by nonrebreather face mask. 4. Notify HCP. 5. Assist with vaginal examination to assess for cord prolapse. 6. assist with amnioinfusion if ordered. 7. Assist with birth if pattern cannot be corrected
The postpartum nurse is assessing a client who delivered a healthy infant by c-section for S/S of superficial venous thromboembolism. Which sign should the nurse note if superficial venous thromobemoblism is present? 1. paleness of the calf area 2. coolness of the calf area 3. enlarged, hardened veins 4. palpable dorsalis pedis pulses
3. Thrombosis of superficial veins usually is accompanied by S/S of inflammation, including swelling, redness, tenderness and warmth of involved extremity, it also may be possible to palpate a large, hardened vein. Clients sometimes also experience pain when they walk. Option 4 is a normal finding.
The nurse is reviewing the HCP's prescriptions for a client admitted for premature ROM. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. monitor FHR continously 2. monitor maternal vital signs frequently 3. perform a vaginal exam every shift 4. administer antibiotic per HCP prescription and per agency protocol
3. Vaginal examinations should not be done routinely on a client with premature ROM because of the risk of infection. Options 1,2,4 are measures to be completed by the nurse.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? SATA. 1. Uterine rigidity 2. uterine tenderness 3. severe abdominal pain 4. bright red vaginal bleeding 5. soft, relaxed, non-tender uterus 6. fundal height may be greater than gestational age
4,5,6. Options 1,2,3 are signs of abruptio placentae
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. encourage ambulation hourly 2. assess VS q4h 3. measure fundal height q4h 4. prepare an ice pack for application to the area
4. A hematoma is a localized collection of blood in the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling in vulvar area. Options 1,2,3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Option 1 increases risk for bleeding. Options 2 and 3 should be assessed more often
The nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is the most appropriate? 1. Notify the HCP of the findings 2. reposition the mother and check the monitor for changes in the fetal tracing 3. take the mother's vitals and tell the mother that bed rest is required to conserve oxygen 4. document the findings and tell the mother that the pattern on the monitor indicates fetal well-being
4. Accelerations are transient increases in the FHR that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve.
The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. I should increase my sodium intake during pregnancy 2. I should lower my blood volume by limiting my fluids 3. I should maintain a low-calorie diet to prevent any weight gain 4. I should drink adequate fluids and increase my intake of high-fiber foods
4. Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and high fiber diet. Sodium intake should be restricted, limited fluids can decrease blood volume - depriving the fetus of nutrients, low calorie diets can be harmful to the fetus
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the med, the nurse should contact the HCP who prescribed the med if which condition is documented in client's history? 1. Hypotension 2. Hypothyroidism 3. Diabeetus Mellitus 4. Peripheral Vasuclar Disease
4. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids.
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. the mother requests that the window be closed before feeding 2. the mother holds the newborn properly during feeding and burping 3. the mother tests the temperature of the formula before initiating feeding 4. the mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding
4. Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmissions to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of the disease transmission.
A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the RR is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. initiate an IV line 2. assess the client's BP 3. prepare to administer morphine sulfate 4. administer oxygen 8-10L/min via face mask
4. If pulmonary embolism is expected oxygen should be administered 8-10L/min by face mask. Oxygen is used to decrease hypoxia. The client is also kept on bedrest with HOB slightly elevated to reduce dypsnea. Option 3 is correct however it is not the initial action. Options 1 and 2 would be completed but only after oxygen has been administered.
The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the HCP? 1. urinary output has increased 2. dependent edema has resolved 3. blood pressure reading is at the prenatal baseline 4. the client complains of a headache and blurred vision
4. If the client complains of a headache and blurred vision, the HCP should be notified, because these are signs of worsening preeclampsia. Options 1,2,3 are normal findings
Fetal distress is occuring with a laboring client. As the nurse prepares the client for a c-section, what is the most important nursing action? 1. slow the IV flow rate 2. continue the oxytocin drip if infusing 3. place the client high fowler's position 4. administer oxygen 8-10L/min via face mask
4. Oxygen is administered to optimize oxygenation of circulating blood. Option 1 is incorrect should be increased to increase maternal blood volume. Option 2 is incorrect because Oxytocin stimulation of the uterus is D/C if fetal patterns change for any reason. Option 3 is incorrect because the client is placed in a lateral, legs elevated, position to increase fetal perfusion
Rh immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the med. The nurse determines that the woman understands the purpose of this med if the woman states that it will protect her next baby from which condition? 1. having Rh positive blood 2. developing rubella infection 3. developing physiological jaundice 4. being affected by Rh incompatibility
4. Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh-positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rh immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura
4. Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the HCP. Options 1,2,3 are normal occurrences in the last trimester of pregnancy.
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1. maternal fatigue 2. coordinated uterine contractions 3. progressive changes in the cervix 4. persistent non reassuring FHR
4. Signs of fetal or maternal compromise include: persistent non reassuring FHR, fetal acidosis, and passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Options 2 and 3 are reassuring signs of labor.
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast feeding her newborn. Which client statement would indicate a need for further instruction? 1. I should breast feed every 2 to 3 hours 2. I should change the breast pads frequently 3. I should wash my hands well before breast feeding 4. I should wash my nipples daily with soap and water
4. Soap is drying and could lead to cracking of the nipples and client should be advised not to use soap on the nipples. Options 1,2,3 are correct measures for the mother to take to prevent mastitis
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the FHR drop from its baseline of 125 to 80. You reposition the mother, provide oxygen, increase intravenous fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed and the FHR remains in the 80s. What additional nursing measures should you take? 1. Notify nursery nurse of imminent delivery 2. Perform a straight cath at this time 3. Start oxytocin (Pitocin) 4. Notify the HCP immediately
4. To relieve a FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If FHR does not resolve after these measures the patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. Options 1 and 2 are not important at this time.
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? 1. I won't be in labor until my baby drops 2. My contractions will be felt in my abdominal area 3. My contractions will not be as painful if I walk around 4. My contractions will increase in duration and intensity
4. True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.
Which finding meets the criteria of a reassuring FHR pattern? 1. FHR does not change as a result of fetal activity 2. Average baseline rate ranges between 100-140bpm 3. Mild late deceleration patterns occur with some contractions 4. Variability averages between
4. Variability indicates a well oxygenated fetus with a functioning autonomic nervous system. FHR should accelerate with fetal movement. Baseline FHR ranges from 110-160bpm. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings.
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? 1. variability 2. accelerations 3. early decelerations 4. variable decelerations
4. Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline FHR. Accelerations are a reassuring sign ad usually occur with fetal movement. Early decelerations result from pressure on the fetal head during contraction.
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. oxygen saturation B. body temp C. serum bilirubin D. HR
A. Surfactant stabilizes the alveoli and helps increase oxygen saturation. Surfactant administration has no direct effect on options B,C,D.
A nurse is reviewing discharge teaching with a client who has a UTI. Which of the following statements by the client indicates an understanding of the teaching? SATA. A. I will perform peri care and apply a perineal pad in a back to front direction B. I will drink cranberry and prune juices to make my urine more acidic C. I will drink large amounts of fluids to flush the bacteria from my urinary tract D. I will go back to breastfeeding after I have finished taking the antibiotic E. I will take Tylenol for any discomfort
B,C,E. Acidification of urine inhibits bacterial multiplication. Increased fluid intake flushes bacteria from tract. Acetaminophen can be taken to reduce discomfort. Option A should be front to back. Breast feeding doesn't have to be delayed while on antibiotic therapy.
A nurse is providing care for a client who is diagnosed with a marginal abruptio placentae. The nurse is aware that which of the following findings are risk factors for developing the condition? SATA. A. fetal position B. blunt abdominal trauma C. cocaine use D. maternal age E. cigarette smoking
B,C,E. Options A and D are not risk factors associated with this condition.
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? A. prolonged labor B. reduced fetal oxygen supply C. delayed cervical dilation D. increased maternal stress
B. Inadequate uterine relaxation results in reduced oxygen supply to the fetus. Precipitous labor, not prolonged labor, is often the result of hypertonic contractions and inadequate uterine relaxation between contractions. Hypertonic contractions and inadequate relaxation of the uterus between contractions does not delay cervical dilation. A hypertonic contractions and inadequate relaxation between contractions will increase maternal distress but this is not an adverse effect.
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an IUD. The nurse should suspect which of the following? A. missed abortion B. ectopic pregnancy C. severe preeclampsia D. hydatidiform mole
B. Manifestations of an ectopic pregnancy include unilateral lower quadrant pain with or without bleeding. Use of an IUD is a risk factor associated with this condition. A client who experienced a missed abortion would report brownish discharge and no pain. A client who has severe preeclampsia does not have vaginal bleeding and presents with right upper quadrant epigastric pain. A client who has hydatidiform ole usually has dark brown vaginal bleeding in the second trimester without abdominal pain
A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. I will take this pill with breakfast B. I will take this medication with a glass of milk C. I plan to drink more orange juice while taking this pill D. I plan to add more calcium rich foods to my diet while taking this medication
C. A diet with increased vitamin C improves the absorption of ferrous sulfate. Ferrous sulfate should be taken on an empty stomach. Milk will decrease absorption. Calcium rich food is appropriate for a client during pregnancy, but it does not improve effectiveness of ferrous sulfate.
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. conjunctivitis B. bronze skin discoloration C. sunken fontanels D. maculopapular skin rash
C. Infants receiving phototherapy are at risk for dehydration from loose stools D/T increased bilirubin excretion. Options A, B,D are important but are not the priority.
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. limit the amount of time the infant nurses on each breast B. nurse the infant only on the unaffected breast until resolved C. completely empty each breast at each feeding or use a pump D. wear a tight-fitting bra until lactation has ceased
C. Instruct the client to completely empty each breast at each feeding to prevent milk stasis, which provides a medium for bacterial growth. Frequent on demand breastfeeding should be encouraged to promote milk flow.
What are the three different types of placenta previa and describe each.
Complete (total) the cervical os is covered by the placenta. Incomplete (partial) the cervical os is only partially covered by the placenta. Marginal (low-lying) the placenta is attached in the lower uterine segment but does not reach the cervical os.
A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what should she expect because her baby is postmature. Which of the following statements should the nurse make? A. your baby will have excess body fat B. your baby will have flat areola without breast buds C. your baby's heels will easily move to his ears D. your baby's skin will have a leathery appearance
D. Leathery, cracked, and wrinkled skin is seen in postmature infants D/T placental insufficiency. Option A is seen in a newborn who is macrosmic. Options B and C would be seen in preterm newborns
A nurse on the postpartum unit is planning acer for a client who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. apply cold compresses to the affected extremity B. massage the affected extremity C. allow the client to ambulate D. measure leg circumfrences
D. Measuring the circumference of the leg assesses for changes in the client's condition. The nurse should plan to apply warm compresses, not massage the clot (can lead to dislodgement), and encourage the client to rest.
A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by the nurse indicates understanding of the teaching? A. obtain an immunization against rubella early in pregnancy B. seek prophylactic treatment if cytomegalovirus is detected during pregnancy C. a woman should avoid crowded places during pregnancy D. a woman should avoid consuming undercooked meat while pregnant
D. Toxoplasmosis, a TORCH infection, is contracted by consuming under cooked meat. Immunization against rubella is contraindicated during pregnancy D/T risk of fetal congenital anomalies. There is no treatment for cytomegalovirus. A TORCH infection cannot be transmitted by being in large crowds.
What are risk factors for placenta previa?
maternal age greater than 35 years, previous placenta previa, uterine scarring, multiple gestations, close pregnancies, smoking, multifetal gestation
