NUR 113 FA DAVIS TEST 2 CHAP 8 - 14 & 16
A client is pregnant with her second child following a cesarean section delivery with the first pregnancy for a breech fetal position. The couple plans to have three children total. What option does the nurse discuss as the best one for this couple? A) Vaginal birth B)Repeat c-section C) External cephalic version D) Only having two children
A
The nurse is assessing the interaction between a newborn and his father. Which statement by the father shows progressed infant-father bonding? Select all that apply. A) "I will stay awake with the baby while his mother sleeps." B) "We're tired, can you take him to the nursery?" C) "I don't change diapers." D) "Will you help me wrap him up?" E) "He looks like his mom."
A D
When educating a non-breastfeeding primiparous patient, what information is important for the nurse to include? Select all that apply. A) "Wear a supportive bra or sports bra 24 hours a day." B) "If your breasts become engorged, you should pump to relieve the pressure." C) "Do not apply ice packs to the breasts because it will stimulation milk production." D) "You can take an analgesic for pain." E) "You may experience milk leakage for the first 1 to 2 weeks."
A D
A nurse is preparing to assist a new mother with breastfeeding following a cesarean section delivery. Which positions will the nurse recommend to maximize patient comfort while breastfeeding? Select all that apply. A) Side-lying position B) Cradle hold C) C-cup positioning D) Using a breast pump E) Football hold
A E
A mother who has been breastfeeding for three months calls the clinic to speak to the nurse. She reports a fever, unilateral breast swelling, pain and redness. She is worried about continuing to breastfeed. What is the appropriate nursing response? A) "Pump and discard your breastmilk until you finish your course of prescribed antibiotics." B) "Massaging the area while you breastfeed will treat the infection." C) "Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today." D) "You need to be more diligent about cleaning your pump supplies."
C
A provider has determined a client needs a cesarean section for cephalopelvic disproportion. The client asks the nurse to explain what cephalopelvic disproportion means. What is the best response by the nurse? a- you are needing a c-section due to the baby experiencing stress from labor b- "Let's focus on preparing for the surgery." c - "The baby is too large for your pelvis." d- "Have you had a recent ultrasound to estimate the baby's weight?"
C
A patient delivered four hours ago after via cesarean section for preeclampsia calls the nurse to the bedside. The patient reports dizziness, diaphoresis and oozing of blood from her current IV site. The nurse determines these findings are consistent with which of the 4 Ts? A) Tone B) Tissue C) Trauma D) Thrombin
D
The nurse is providing teaching to new parents regarding the levels of fatigue that may occur following childbirth. Which statement should the nurse include in the teaching? A) "You are going to feel less fatigued after 3 months of having your infant at home." B) "Since you are younger parents, you will feel less fatigued than an older parent would." C) "Older mothers tend to report higher levels of stress than younger mothers." D) "Mothers tend to be more fatigued than fathers following the birth of a new infant."
D
The nurse is caring for a patient on the postpartum unit who has been diagnosed with subinvolution post-delivery. The nurse understands that subinvolution is associated with what labor and birth complications? A) Coagulation disorders such as DIC. B) Postpartum hemorrhage due to perineal laceration. C) Uterine tetany and overproduction of oxytocin. D) Retained placental tissue and infection. E) Presence of uterine fibroids.
D E
A client was recently admitted to the labor and delivery unit in active labor. The nurse performs Leopold's maneuvers during the assessment. During the third maneuver, the nurse notes a firm and fixed fetal part. Which position correlates with this assessment finding? a- occiput b- acromion c- sacrum d- transverse
a
A laboring patient is experiencing labor dystocia. Which statement correctly describes labor dystocia? a- difficulty labor characterized by abnormally slow labor progress b- fetal shoulder impacted under the maternal symphysis pubis c- fetal head larger than maternal pelvis d- uterine contractions > 25 mm Hg w/ intrauterine pressure catheter
a
A nursing instructor explains to a group of students that an amnioinfusion is a procedure used most commonly in the first stage of labor to treat which type of decelerations? a- variable b- late c- early d- prolonged
a
While assessing a pregnant patient, the nurse notes the fetal heart rate (FHR) is 125 with moderate variability, no accelerations and no decelerations. Using the National Institute of Child Health and Human Development (NICHD) Criteria, which would the nurse record as the appropriate category related to the assessment findings? a- category I: strongly predictive of a well-oxygenated, non-acidotic fetus. no action required. b- category II- indeterminate. requires continued surveillance & reevaluation c- category III- abnormal requiring prompt evaluation & intervention d- Category IV- fetal demise
a
A client is admitted to the labor and delivery unit in active labor. There has been no prenatal care for the current pregnancy, and the on-call provider estimates the pregnancy to be around 35 weeks' gestation. Which medication will the nurse anticipate being ordered for on this client? a- oxytocin b- penicillin c- magnesium sulfate d- metoclopramide
b
A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient does the nurse assess as being at the highest risk for fluid volume overload? A) A G1P0 who had an epidural for 6 hours during labor B) A G3P2 who was induced with Pitocin for preeclampsia C) A G8P2 with insulin-controlled gestational diabetes D) A G2P2 who had a repeat cesarean section 24 hours ago
b
The nurse is caring for a patient who is undergoing a term gestation pregnancy induction. Which is the nurse aware of regarding the induction of labor? a- it is achieved by external & internal version techniques b- it is always done for medical indications c- it is rated for probability of success by a Bishop score d- it is only achieved through oxytocin infusion
c
The nursing instructor has just completed a lecture on fetal surveillance and the use of structured intermittent auscultation (SIA). The instructor knows that teaching was effective when the students recognize which contradiction to the use of SIA? a- 32 year old G 1, P 0 pt at 40 weeks who is 6 cm dilated w/ category I tracing b- presence of nurses & providers experienced in SIA c- institutional policy addressing technique & frequency of SIA d- 26 year old G 4 P3 at 39 weeks who is 3 cm dilated w/ category I tracing, being induced for gestational diabetes mellitus (GDM)
d
While caring for a pregnant client, which can the nurse provide to decrease fear and anxiety throughout labor and delivery? a- ambulation b- confidence c- pain medication d- labor support
d
A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider? A) Boggy uterus B) Bilateral lower extremity numbness C) Uncontrollable shaking D) Moderate vaginal bleeding
A
Following a cesarean section a few hours ago, the partner of a client comes out to the nurses' station to report severe itchiness the client is experiencing. The partner voices concern that the client is experiencing an allergic reaction to the morphine given during surgery. How does the nurse respond to the client when entering to the room to assess the itching? A) "Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy." B) "Here is some medication to stop the itching." C) "I will note in your medical record that you have an allergy to morphine." D) "Let me call the provider and report the itching."
A
Immediately after birth, the nurse notes the patient's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? A) Document the findings as within normal limits B) Perform fundal massage C) Instruct the woman to empty her bladder D) Reassess every 5 minutes
A
The nurse assesses a mother's bonding with her new baby. Which action made by the mother does the nurse identify as the initial maternal phase? A) The mother relives and speaks of the birthing experience B) The mother responding and picking up the infant when she cries C) The mother goes back to work. D) The mother asking questions about infant care
A
The nurse is assessing a patient who is a G5T5P0A0L5 and delivered vaginally four hours ago. The patient's labor history included a 16 hour oxytocin induction for a macrosomic infant. Assessment findings include a boggy uterus and a completely saturated peri pad with the presence of blood clots. What does the nurse identify as the most likely cause for the increased bleeding? A) Tone B) Tissue C) Trauma D) Thrombin
A
The nurse is caring for a patient following the delivery of a 36-week infant due to maternal preeclampsia. The infant is stable and rooming-in with the mother. The nurse observes the mother demonstrating a slow response to the infant cues. What does nurse attribute this slow response to? A) Magnesium sulfate infusion B) Increased blood pressure C) Hyperactive reflexes D) Subtle cues due to prematurity
A
The nurse is caring for a patient that speaks Spanish. When using an interpreter, it's inappropriate to use which phrase when talking to the patient? A) \"Tell her it\"s okay and I will be here with her.\" B) \"You\"re 5cm dilated, which means you are halfway to having to push.\" C) \"You baby needs to eat, how can I help you feed her?\" D) \"Did you baby have a wet diaper or a dirty diaper?\"
A
The nurse is caring for a patient who delivered via cesarean section two hours ago and is now in the recovery room. Upon reviewing the delivery record, the nurse notices that her estimated blood loss was 800mL. What is the appropriate nursing intervention? A) Document on the report sheet as "normal" and proceed with plan of care. B) Call the provider to obtain an order for a complete blood count (CBC) and IV fluids. C) Explain to the patient that she will not be able to breastfeed until her hemoglobin and hematocrit increases by 10%. D) Prepare the patient for a dilation and curettage (D&C)
A
The nurse is describing the transition to parenthood during a childbirth education course. During the class, the nurse mentions that most knowledge of parental expectations comes through observation of other parents. What term does the nurse use to describe this knowledge acquisition? A) Incidental B) Intentional C) Instructional D) Interrogation
A
The nurse is preparing a client for a cesarean section. Following the epidural anesthesia, the nurse is ready to show the partner where to stay during the surgery. Where does the nurse show the partner to go? A) On a stool next to the client's head. B) On a stool next to the infant warmer. C) In a waiting room next to the operating room. D) In the recovery room, to await completion of the surgery.
A
The nurse walks into a postpartum room noting a screaming infant in a crib near the bedside. Both parents are asleep. Which statement by the mother shows the need for further assessment for ineffective bonding? A) "Sorry, it won't stop crying, and we are so tired." B) "We are so tired, she kept us up all night." C) "We are so tired, we must have been sound asleep." D) "We are so tired. What if this happens at home?"
A
The oncoming nurse is reviewing her assignment for the day, and would like to identify who see first based on acuity. Which woman is at greatest risk for primary postpartum hemorrhage? A) A G5P4 patient with obesity and undergoing labor induction. B) A G2P2 patient who delivered a baby vaginally after an 8-hour labor augmented by oxytocin. C) A G1P1 woman who just delivered via emergency cesarean section for fetal distress. D) A G2P2 woman delivering vaginally after a cesarean section with her first pregnancy.
A
When performing a fundal assessment on a patient, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this patient? A) Massage the fundus with the palm of the hand B) Place an indwelling catheter C) Notify the physician or midwife D) Give Oxytocin as per the physician's orders
A
While the nurse is preparing a client for an emergency cesarean section, the family voices concern that the client is extremely nervous about the procedure. How does the nurse respond to the client? A) "Tell me about how you are feeling right now." B) "We do many c-sections every day, you will be fine." C) "I am going to insert the foley catheter now." D) "It is important that you try to calm down for the baby."
A
A nurse is caring for a G2P2 patient in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this patient? Select all that apply. A) Assess the uterus for location, position and tone of fundus every 15 minutes B) Titrate IV Oxytocin infusion rate to uterine tone C) Provide information regarding afterpains D) Assess lochia for color, amount, and odor E) Inspect the inside of the vagina for tearing
A B C D
Why is it important for nurses to understand cultural competence for parental phases? A) Cultural beliefs can influence the woman's behaviors and the amount of time she spends in each phase. B) Cultural beliefs influence the degree of the father\"s care for the infant. C) Cultural beliefs can affect the role of extended family members. D) Cultural beliefs can influence the infant\"s name. E) Cultural beliefs can influence parental decisions when disciplining a young child.
A B C D
During an office visit at 2-weeks postpartum, the gravida 3, para 3 patient, she mentions an increase in stress level following delivery of this child. The nurse explains that the increase may be attributed to which considerations? Select all that apply. A) Increase in childcare tasks B) Financial concerns C) Lack of paternal participation D) Increase in fatigue level E) Decrease in partner intimacy
A B D
A postpartum nurse caring for a patient who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this patient? A) Assess the position, tone and location of the fundus B) Massage a boggy uterus C) Document the findings and reassess in 1 hour D) Quantify blood loss E)Instruct the client to void and reevaluate
A B D E
While presenting an educational session on childbirth the nurse was asked to discuss risk factors requiring a cesarean section. What should the nurse include in her response? Select all that apply. a- advanced maternal age b- spontaneous labor onset c- breech position d- maternal request e- multiparity
A C
A mother-baby nurse just received report on four mother baby couplets and is preparing to start the first assessments of the shift. All are recovering from cesarean section deliveries. Which couplet will need to be seen first? A) Couplet #1: the infant and mother have been doing well since delivery 3 days ago and would like to be discharged in the next couple hours. B) Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm. C) Couplet #3: the mother has chosen to bottle feed the infant, and the infant has lost 89 grams of the 3200-gram birth weight at 2 days of age D) Couplet #4: the infant has been experiencing difficulties latching on to breastfeed and last nursed successfully an hour and a half ago.
B
A nurse is caring for a client following a cesarean section four hours ago that occurred due to arrest of labor. Initially, the client was admitted to the hospital two days ago after experiencing spontaneous rupture of membranes. Which medication order does the nurse anticipate for this client? A) Bisacodyl B) Ampicillin C) Methergine D) Dexamethasone
B
A nurse is caring for a patient in the first hour following a vaginal delivery. What is the priority nursing intervention? A) Facilitate bonding between the mother and infant B) Assess the fundus for location, position and tone C) Administer pain medications D) Inspect the perineum for tearing
B
A postpartum patient expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? A) "Blood clots do not run in families, so you have nothing to worry about." B) "I understand your concern. Let's take a look at the back of your legs together." C) "Women are only at risk for developing blood clots during pregnancy." D) "I will assist you to ambulate around the hallway so that doesn't happen."
B
A primiparous patient tells the nurse she wants to bottle-feed her baby. What is the most therapeutic response by the nurse? A) "Have you tried breastfeeding? Let's see if we can get baby to latch." B) "You'll want to wear a sports bra for 24 hours a day until your breasts are soft." C) "We do not advocate bottle-feeding, so you'll need to bring your own formula." D) "Are you sure? Breastmilk is so much healthier for your baby."
B
The nurse is caring for a patient who was diagnosed with gestational diabetes mellitus (GDM) at 28 weeks of pregnancy. The patient had an uncomplicated vaginal birth 12 hours ago. Which statement made by the patient would require further education? A) "Breastfeeding my baby will help reduce my risk for developing Type II diabetes." B) "My diabetes will resolve in the next few weeks, so there is no need for follow up." C) "I have a much higher risk of developing Type II diabetes now that I have had gestational diabetes." D) "I need to see a provider for preconception glucose control prior to my next pregnancy."
B
The nurse is caring for a primiparous woman who just delivered her child. Which action should the nurse take to adhere to the taking-in stage? A) Help the mother change the diaper. B) Give the patient time to reflect. C) Start to teach about her new mother body. D) Start to promote maternal independence.
B
The recovery room nurse is completing a postpartum assessment on a newly delivered patient. Upon assessment, the nurse finds the peripad saturated with lochia, with large, visible clots. What is the priority nursing intervention based on these findings? A) Document the findings on the medical record. B) Massage the uterus until firm. C) Start an IV and give a bolus of oxytocin. D) Walk the patient to the bathroom.
B
While assessing a post-operative cesarean section client, the nurse notes a temperature of 102.1?. Prior to calling the provider, what other assessment should the nurse complete to include when reporting the concern? A) Identify the time of last pain medication B) Assess the c-section incision C) Assess lung sounds and incentive spirometry D) Assess uterine fundus and lochia
B
Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply. A) "My uterus will stay this big until I get my period again." B) "It will take between 6-8 weeks for my uterus to return to normal size." C) "Contractions will cause my uterus to shrink." D) "My uterus will not be as small as it was before I had a baby." E) "My uterus will return to the size of a volleyball."
B C
The nurse is discussing the stages of "becoming a mother" with a patient. In what order will the nurse review the stages? A) achieving maternal identity B) commitment & preparation for infant C) increasing attachment to infant D) moving toward a new normal
B C D A
The nurse understands that different factors influence role transitions for new parents. Which of these factors are included? Select all that apply. A) Living on their own B) How they were parented C) Length of the relationship between partners D) Education E) Finances
B C D E
The nurse is preparing a class for first time expectant fathers and are all anticipating delivery in the next couple of months. What known themes for expectant fathers will the nurse include during the class? Select all that apply. A) Paternal involvement. B) Fathering older children. C) Parenting support. D) College savings. E) Being there for the child.
B C E
Following cesarean delivery, a stable female infant weighing 3,126 grams is placed skin-to-skin with the mother. The client's partner asks why the infant is placed with the mother during the remainder of the surgery. What is the best response from the nurse? A) "Placing the infant with the mother reduces the need to have another nurse in the crowded operating room." B) "We can discuss this later, I need to help the surgeon right now." C) "Infants are less likely to need NICU care when placed skin-to-skin with the mother." D) "It is important to get a picture immediately after delivery of the infant."
C
In addition to assessing bowel sounds, what other priority gastrointestinal assessment should be completed on a client following a cesarean section delivery? A) Assessing for nausea B) Last bowel movement before surgery C) Assessing for flatulence D) Tolerance of a full liquid diet
C
The obstetric nurse is preparing a client for an epidural. What is the priority nursing intervention prior to this procedure? A) Monitor fetal heart tones B) Obtain maternal blood pressure C) Administer IV fluid bolus D) Assess for prior epidural anesthesia
C
A nurse observes a 14-year-old and her new baby. The nurse notes the grandmother doing most of the holding and care of the infant. What is the appropriate nursing intervention? A) Show the patient more baby care videos and ask if she is depressed B) Tell the mother, "It"s time to grow up." C) Point out how well the grandmother is doing with the infant. D) Tell the patient how well she does when she does the care for the infant.
D
A perinatal nurse is educating a patient with preeclampsia about potential complications during delivery. What important information should the nurse include in the teaching? A) "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 2 weeks postpartum." B) "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 weeks postpartum." C) "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 months postpartum." D) "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum."
D
A postpartum mother delivered two hours ago and has a history of recurrent urinary tract infections (UTIs). She is very anxious about the risk of UTI after delivery and asks the nurse what she can do to decrease her risk. Which response by the nurse would require further education regarding recommendations to prevent UTI? A) "If you are unable to get up and walk to the bathroom to void in the next hour, I will need to insert a catheter to empty your bladder." B) "I will need you to keep track of your urine output with the goal of voiding at least 150 mL." C) "It is important to be changing your peri pad every 3-4 hours." D) "I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."
D
Following a cesarean section, the nurse caring for the client notes the following assessment data: Temperature 99.1?, Heart rate 136, Respirations 20, Blood pressure 82/48, and skin pale and clammy to the touch. The nurse reports concern of what postpartum complication to the provider? A) Respiratory depression B) Renal failure C) Wound infection D) Postpartum hemorrhage
D
The nurse is assessing a new mother who brought her 6-month-old infant for a well check. The mother is 16-years-old and her mother came with her to the visit. The infant's grandmother is holding the new baby and answering all of the questions. What part of the becoming a mother process does the nurse note to be lacking? A) Commitment, attachment and preparation B) Acquaintance and learning to care C) Learning a new normal D) Achieving maternal identity
D
The nurse is assessing client 12 hours post cesarean section delivery, of a healthy male infant weighing 9 pounds 3 ounces. The client's Foley catheter was removed three hours ago. Which subjective assessment data requires immediate intervention? A) The client reports pain at a level of four and can tolerate a five. B) The client reports the infant nursed for about 20 minutes one and a half hours ago. C) The client has a blood pressure of 92/48. D) The client reports no voiding since the catheter was removed.
D
The nurse is caring for patient newly diagnosed with endometritis. What assessment findings are consistent with endometritis? A) Abdominal cramping and cloudy urine B) Dizziness and hypotension C) Edema and hypertension D) Uterine tenderness and foul-smelling lochia
D
The nurse is instructing a woman and her partner on non-pharmacological pain relief interventions such as effleurage and using heat/cold. The client asks how these techniques work to manage pain. Which is the best statement by the nurse? a- only a certain number of sensations can travel to the brain at once. we replace pain signals w/ pleasure signals to reduce discomfort b- massage & heat reduce blow flow to tissues & temporarily numb the nerve fibers c- the placebo effect makes the client believe their pain is less, even though there is no physiologic benefit of the techniques d- the effects are only useful in latent phase labor. As active labor starts, she will likely need opioid pain medication
a
The Labor and Delivery (L&D) unit educator discusses the prioritization of fetal monitoring goals, creating a plan of care, and setting goals for implementation with a group of nurses. Which goals are correct? Select all that apply. a- interpretation of ongoing assessment of fetal oxygenation b- prevention of significant fetal academia c- minimize unnecessary interventions d- promote a satisfying family-centered birth experience e- use of EFM for all laboring women in US is required
a b c d
The Labor and Delivery (L&D) educator has explained to a group of nurses how the utero-placental unit functions. Which components are necessary for the fetus to receive appropriate oxygenation? Select all that apply. a- adequate oxygenation of mother b- adequate utter-placental circulation c- adequate umbilical circulation d- adequate fetal blood volume e- adequate blood flow to placenta
a b c e
Which assessments of uterine activity are obtained by the nurse when the patient has an intrauterine pressure catheter (IUPC) placed? Select all that apply. a- frequency b- intensity c- duration d- fetal heart rate e- resting tone
a b c e
Which nursing interventions would support a normal, physiologic birth? Select all that apply. a- waiting until 40 weeks gestation to induce labor b- assisting the mother to change positions frequently c- collaborating w/ a doula or other support person to manage discomfort d- encouraging the mother to lie on her back & place her feet in stirrups for delivery e- allowing the bag of waters to rupture spontaneously
a b c e
The labor nurse is caring for a patient at risk for intraamniotic infection. Which assessment findings would alert the nurse of intraamniotic infection? Select all that apply. a- baseline fetal heart rate 170 b- maternal fever c- meconium stained amniotic fluid d- severe headache e- foul-smelling vaginal discharge
a b e
The postpartum nurse is preparing to administer Rh (D) Immune Globulin (RhoGAM) to a post- cesarean section patient on the mother-baby unit. What statements made by the patient indicate an understanding of RhoGAM? Select all that apply. A) "I need this because my blood type is negative and my baby is positive." B) "I will avoid pregnancy for 4 weeks." C) "This medication will help protect my future babies." D) "I only need to get this once in my lifetime." E) "I need to receive RhoGAM within 48 hours of giving birth."
a c
The nurse is preparing a group session for childbirth preparation. The topic will include signs of impending labor. The nurse will include which topics? Select all that apply. a- lightening b- decreased fetal movement c- nesting d- bloody show e- weight gain
a c d
The nurse is describing baseline fetal heart rate (FHR) to a practicum student. which would the nurse mention when teaching about the definition and assessment criteria related to baseline FHR? Select all that apply a- periodic changes in baseline of FHR occur in relation to uterine contractions b- recurrent changes in baseline of FHR occur in less than 50% of contractions in 20 mins c- intermittent changes in baseline of FHR occur in greater than 50% of contractions in 20 mins d- episodic changes in baseline of FHR occur independent of uterine contractions e- FHR is rounded to increments of 5 bpm during a 10 min window. This must be at least 2 mins of identifiable baseline segment
a d e
A term laboring patient is reporting severe lower back pain and has been pushing for two hours. The nurse would anticipate that the fetus is in which position? a- frank breech b- occiput posterior c- occiput anterior d- shoulder presentation
b
A woman in the second stage of labor has been pushing for 3 hours. The provider is preparing for a vacuum-assisted delivery. Which anticipatory guidance should the nurse give to the patient? a- the blades of the forceps will be applied to the fetal head b- the baby may have some bruising & edema of the head c- you will need to push b/t contractions d- an episiotomy is required for a vacuum delivery
b
The grandmother of a newly-delivered infant was in the room for the delivery. The newborn is placed skin-to-skin with the mother and covered with a warm blanket while waiting for the placenta to deliver. The grandmother expresses concern that the newborn is too cold with no clothes on. Which is the best response by the nurse? a- I will check the temp when I have time b- skin-to-skin contact helps newborns to regulate temp c- please just stand out of the way of the provider d- the warm blanket will stop all cold air from reaching the baby
b
The nurse is caring for a client who has been dilated to 10 cm for about one hour. When assessing the client, her mother asks why the nurse has not started telling her daughter to push. Which is the appropriate response from the nurse? a - times are different now, we do not make women push if they do not want to b- the baby does better at birth if the mother waits to push once she feels the urge c- it is best to start pushing 1 hour after reaching full dilation. It will start soon d- the provider is not here yet, so pushing must be delayed
b
The nurse is caring for a patient following a precipitous delivery. Which complication would the nurse watch for? a- retained placenta b- postpartum hemorrhage c- hemorrhoids d- uterine rupture
b
The nurse is caring for a patient that is being induced with oxytocin. Upon assessment of the oxytocin infusion and patient status, the nurse would determine effectiveness with which clinical finding? a- pt reports a pain level of 4 on numeric pain scale w/ blood shown noted on the peripad b- contractions last 40 to 60 secs every 2-3 mins w/ cervical change c- contractions are 4 to 5 minutes apart lasting 30 to 40 secs w/ no cervical change d- intensity of contractions is at least 75 to 100 mm/Hg with IUPC
b
The nurse is caring for a patient whose fetus has been diagnosed with Intrauterine Growth Restriction (IUGR). The patient asks the nurse how this could have happened. Which does the nurse recognize as a possible cause? a- the fetus has a lower oxygen tension then an adult b- available oxygen chronically falls below 50% of normal levels & there is a redistribution of blood to vital organs c- the amount of lactic acid exceeds fetal buffering capacity d- oxygenated blood from mother is delivered to the intervillous space in the placenta
b
Upon admission, the nurse instructed a 39-week gestation client to lie on her back in bed for assessment and placement of the fetal monitor. After going through the medical history, the nurse assesses the client's blood pressure at 76/42. Which is the appropriate intervention? a- retake the BP w/ manual cuff b- move client onto her left side c- call provider to obtain an order for IV fluids d- continue to monitor bp every 30 mins
b
When palpating the patient's fundus during a contraction, the nurse notes that it feels like a 'chin.' The nurse documents this finding as which contraction intensity? a- mild b- moderate c- strong d- firm
b
A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. A) "You had a fever during labor and the antibiotics have not started working yet." B) "The hard work of labor can cause your temperature to increase." C) "It is common for women to experience mild temperature elevation after giving birth." D) "Your body is going through a lot of hormonal changes right now, which can increase your temperature." E) "Do you feel hot? I will get you some Tylenol."
b c d
The nurse has just completed a fetal monitoring course and is explaining the normal findings of structured intermittent auscultation (SIA) with a handheld Doppler. Which would the nurse identify as a normal finding of SIA? Select all that apply. a- moderate variability b- normal baseline b/t 110 - 160 bpm c- regular rhythm d- presence of FHR increases from baseline e- absence of FHR decreases from baseline
b c d e
The nurse is assessing a laboring client. Which signs and symptoms does the nurse recognize that indicate movement into the transition phase of labor? Select all that apply. a- contractions every 3 - 4 mins b- contractions lasting 60 - 90 seconds c- cervix dilated to 8 cm d- noted trembling of client e- increase in client anxiety
b c d e
The charge nurse is observing a new nurse on the labor and delivery floor caring for a client in active labor and recognizes the need for additional training. Which care provided by the new nurse demonstrates a need for further orientation? Select all that apply. a- the new nurse encourages client to use the restroom every hour b- the new nurse recommends client stay in bed & rests until it is time to push c- the new nurse explains all procedures to the client throughout the shift d- the new nurse suggests that all family members leave the room e- the new nurse assists client w/ breathing techniques to help w/ relaxation
b d
The instructor is teaching the modes of fetal heart rate and contraction assessment to a class of nursing students. What are the modes of uterine monitoring? Select all that apply. a- auscultation b- palpation c- fetal spiral electrode d- intrauterine pressure catheter e- tocodynamometer
b d e
The nurse is teaching a childbirth education class. Which statements regarding induction of labor would be included in the teaching? Select all that apply. a- labor induction is used only for medical reasons b- prior to using oxytocin for labor induction, the cervix should be favorable c- as long as you are over 37 weeks gestation, your doctor may induce you for convenience d- the risks of labor induction are the same as the risks w/ spontaneous labor e- you should not have a labor induction if you have active herpes
b e
A patient in labor is noted to have an occiput posterior presentation. Which complications would the nurse anticipate? a- prolapsed cord b- facial bruising in neonate c- dystocia d- shortened 2nd stage
c
The nurse instructs the client on second stage positioning and pushing techniques. The nurse recognizes that the client understands the teaching when the client states: a- holding my breath helps increase pressure & push the baby out b- having my legs in stirrups reduces the risk that I will tear c- pushing on my side can increase blood flow to the baby d- I should begin pushing as soon as I am completely dilated
c
The nurse is caring for an obese patient and having difficulty maintaining the fetal heart rate (FHR) and contractions on an external fetal monitor (EFM). Which is the best action by the nurse in this situation? a- notify the provider & document b- insert intrauterine pressure catheter (IUPC) & fetal spiral/scalp electrode (FSE) c- reposition pt, adjust tocodynamometer & ultrasound transducer d- discontinue EFM & notify provider
c
The process of labor is multifactorial. The five primary factors include powers, passage, passenger, psyche, and a- pressure b- patience c- position d- pelvis
c
While caring for a client, which interventions would the nurse include in the nursing care plan to provide culturally competent care? Select all that apply. a- describe hospital protocols that will be followed during the delivery b- provide teaching on non-pharmacological pain management options as they are preferred by women of the client's culture c- identify who the woman prefers to care for her during labor & delivery d- provide the client's preferred foods as appropriate or encourage the client's family to bring foods from home e- determine who is the client's support person(s) & how they will participate in her care
c d e
The nurse is in the room with a laboring patient who was found to have a prolapsed umbilical cord. The nurse will place the patient in which positions to help relieve pressure on the cord? Select all that apply. a- high- fowlers b- left lateral c- knee-chest d- squatting e- trendelenburg
c e
A client requests to keep the placenta following delivery. How would the nurse respond to this request? a- we do not allow that in this hospital. It is against all regulations b- can you tell me what you plan to do with the placenta? we only allow this if you plan to bury the placenta c- why would you want to take that home? it will begin to smell & can attract insects d- I understand that this is very important to you, and I will see what I can do to honor this request
d
A gravid patient in labor suddenly has dyspnea, hypotension, frothy sputum, and loss of consciousness. The nurse knows these are signs and symptoms of which obstetrical emergency? a- placental abruption b- uterine rupture c- uterine inversion d- amniotic fluid embolism
d
A gravid patient is having a trial of labor after cesarean (TOLAC). The nurse knows to watch for which obstetrical emergency? a- dystocia b- shoulder dystocia c- amniotic fluid embolism d- uterine rupture
d
Regarding oxytocin for labor induction, what is the most concerning side effect of oxytocin? a - fetal heart rate baseline change from 140 to 130 bpm b- increased BP c- oliguria d- tachysystole
d
The OB nurse is assessing a patient utilizing structured intermittent auscultation (SIA). Which intervention assists the nurse in identifying fetal heart tones (FHT)? a- perform a 20 minute Non-Stress Test (NST) b- auscultate fetal heart tones (FHT) for at least 20 mins c- auscultate FHT's during & after contractions for 30 seconds d- auscultate FHT's b/t contractions for at least 30 - 60 seconds
d
The nurse caring for a multiparous patient in active labor suspects cephalopelvic disproportion (CPD). Which assessment finding supports this? a- fetal station descending b- large maternal stature c- tachysystole d- fetus not engaged in the pelvis
d
The nurse is assessing a pregnant patient who is externally monitored and contracting every 3 to 4 minutes with each contraction lasting 40 to 60 seconds. The peak of the contraction reads 90 on the graph paper with a resting tone of 20. The patient rates her contractions as 10/10 and is crying. Which can the nurse document, based on these findings? a- contractions are very strong & pt will probably deliver soon b- contractions are not adequate to make cervical changes c- resting tone is too high d- frequency & duration of contractions
d
The nurse is caring for a term gestation laboring patient who just had a sudden onset of hypoxia and hypotension shortly after spontaneous rupture of membranes. Which is the nurse's priority action? a- assist the pt into high-fowler's position b- call the provider & prepare for imminent delivery c- draw a blood panel & prepare to administer blood products d- provide supplemental oxygen & left uterine displacement
d
The nurse notes a fetal heart rate (FHR) deceleration that begins after the peak of the contraction and ends once the contraction is over. Which is the priority nursing action for this patient? a- administer oxygen at 10 L/min via nonrebreather face mask b- give IV bolus c- discontinue oxytocin d- change the maternal position
d
A nurse is caring for a patient in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order. - Increase frequency of vital signs - perform fundal massage - notify the physician or midwife of excessive blood loss -achieve free-flowing venous access
perform fundal massage notify the physician or midwife of excessive blood loss achieve free-flowing venous access increase frequency of vital signs
