NUR 202 Mod F Quiz
A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiologic response indicates to the nurse that the magnesium sulfate is having a therapeutic effect?
A decrease in frequency and duration of contractions The purpose of administering magnesium sulfate is to stop preterm labor. It is a tocolytic agent that relaxes uterine smooth muscle.
A 37-year-old client with type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What is the primary risk factor in the client's history that indicates a need for the NST?
The risk for placental insufficiency Pregnant women with diabetes are prone to placental insufficiency, which can threaten fetal well-being
A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first when repetitive late decelerations of the fetal heart rate are observed?
Discontinue the oxytocin infusion The infusion should be stopped because it is the likely source of fetal compromise.
As a means of halting preterm labor a client is started on terbutaline (Brethine). For which side effect of this medication should the nurse monitor the client?
Widening pulse pressure A widening pulse pressure is a side effect of terbutaline
A client in preterm labor does not respond to therapy, and birth seems imminent. The client begins to cry and says, "I'm so worried about my baby." What is the nurse's best response?
"All of this must leave you very confused and frightened." Focusing on the mother's feelings permits her to express fears and concerns.
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?
Discontinuing the test because the pattern is within the expected rang . The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period
A 30-year-old gravida 1 para 0 experienced a miscarriage at 10 weeks' gestation. She is Rh negative. In light of this information, the nurse expects:
A prescription for one intramuscular microdose (50 mcg) of RhoGAM To prevent production of anti-Rh (D) antibodies in a Rh-negative woman who has been exposed to Rh-positive blood, a microdose of RhoGAM must be administered intramuscularly because the pregnancy ended in the first trimester
A nurse is caring for a client in preterm labor who is receiving a course of corticosteroids to promote fetal lung maturity. What test may be used to most accurately determine fetal lung maturity?
Amniocentesis
A client in preterm labor at 35 weeks' gestation asks the nurse, "What determines whether my baby's lungs will be okay?" The nurse explains that a test of the amniotic fluid obtained through amniocentesis will reflect fetal lung maturity. Which test should the nurse include in the discussion?
Phosphatidylglycerol Phosphatidylglycerol is a phospholipid that, if present in the amniotic fluid, indicates that the fetus's lungs are mature.
A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?
Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces.
A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the health care provider to prescribe?
Dexamethasone Dexamethasone is a glucocorticoid that stimulates the production of fetal lung surfactants, which are needed for fetal lung maturity; administration is started 48 hours before the expected birth.
A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect?
Placenta previa A nontender uterus and bright-red bleeding are classic signs of placenta previa; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed
While caring for a client in labor, a nurse notes that during a contraction there is a 15-beat/min acceleration of the fetal heart rate above the baseline. What is the nurse's next action?
Record the fetal response to contractions and continue to monitor the heart rate Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. This increase in the fetal heart rate does not require intervention at this time.
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect her diet and insulin needs. How should the nurse respond?
"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring." Insulin requirements may decrease in early pregnancy because of increased fetal needs for nutrients and the possibility of maternal nausea and vomiting. Insulin requirements increase in the second and third trimesters as resistance to insulin develops. The blood glucose level is monitored to prevent ketoacidosis and harm to both the mother and fetus
While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats/min that lasts 15 seconds. How should the nurse document this event?
An acceleration An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate.
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. What does the nurse suspect precipitated this preterm labor?
Incompetent cervix An incompetent cervix indicates a short cervix, cervical scarring from previous births, or cervical or uterine anomalies. It puts the client at risk for second-trimester miscarriage
External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?
Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends The reading noted by the nurse represents early decelerations that occur with head compression during a contraction, with the fetal heart rate (FHR) returning to baseline at the end of the contraction.
Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks.
G4, T1, P1, A1, L3 Four pregnancies = G (gravida) 4. One pregnancy that ended at 38 weeks = T (term) 1. One pregnancy that ended at 32 weeks = P (preterm) 1. One pregnancy that ended at 18 weeks = A (abortion) 1. One set of twins and a singleton = L (living) 3.
A nurse is caring for a client with a history of treatment for preterm labor during this pregnancy. The client now is at 33 weeks' gestation. With regard to sexual intercourse, the nurse should explain that it is:
Eliminated to prevent stimulation of uterine activity Prostaglandins in semen may stimulate labor, and penile contact with the cervix may increase myometrial contractility. Sexual intercourse may cause labor to progress
A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates:
Fetal well-being Nonperiodic accelerations with fetal movement indicate fetal well-being
A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate shows:
Late decelerations The fetus with a borderline cardiac reserve will demonstrate hypoxia by a decreased heart rate when there is minimal stress, making the CST result positive
A client at 30 weeks' gestation is admitted in preterm labor. An intravenous solution of the tocolytic agent ritodrine (Yutopar) is started. The nurse prepares to administer an intramuscular injection of betamethasone (Celestone). The client asks why betamethasone is being administered. The nurse responds, "It:
Stimulates fetal lung maturity" It stimulates the release of enzymes that produce lung surfactant, which promotes fetal lung maturity
A pregnant client with a history of preterm labor is at home on bedrest. What instructions should a teaching plan for this client include?
Lie on the side with the head raised on a small pillow Bedrest keeps the pressure of the fetal head off the cervix. The side-lying position keeps the gravid uterus from impeding blood flow through major vessels, thus maintaining uterine perfusion.
A client who had tocolytic therapy for preterm labor is being discharged. What instructions should the nurse include in the teaching plan?
Limit daily activities Although it has not been proved that bedrest limits preterm labor, it is often recommended; activities are restricted to bathroom privileges and movement to a daytime resting area.
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time?
Helping the client change her position Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because it increases placental perfusion.
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client?
Insulin needs will increase during the second trimester The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status.
A nurse administers two serial intramuscular injections of betamethasone (Celestone) to a woman at 32 weeks' gestation who has been admitted in preterm labor. The nurse knows that this medication is given to:
Stimulate surfactant production Corticosteroids stimulate surfactant production; they also have been shown to reduce the incidence of intraventricular hemorrhage.
A woman at 39 weeks' gestation whose membranes have ruptured at home arrives at the clinic to be evaluated. Assessment reveals mild irregular contractions 10 to 15 minutes apart and a fetal heart rate (FHR) of 186 beats/min is auscultated between contractions. In light of this assessment, what does the nurse conclude?
A further assessment is necessary The fetal heart rate should be 110 to 160 beats/min; an FHR of 186 is tachycardic and further evaluation is necessary because the fetus may be at risk.
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?
Assessing maternal vital signs A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations
Insulin requirements may decrease in early pregnancy because of increased fetal needs for nutrients and the possibility of maternal nausea and vomiting. Insulin requirements increase in the second and third trimesters as resistance to insulin develops. The blood glucose level is monitored to prevent ketoacidosis and harm to both the mother and fetus
Repeatedly drops abruptly to 90 beats/min unrelated to contractions This fetal heart rate change is known as variable-type decelerations. This is indicative of umbilical cord compression that, left uncorrected, may lead to fetal compromise; interventions are directed at improving umbilical circulation.
A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time?
Promotion of maternal and fetal well-being during labor Labor is continuing, and promotion of the well-being of both client and fetus is the priority nursing care during this period.
A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response?
"A beta-adrenergic." Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily.
The nurse is caring for a first-time mother at her first prenatal visit. The client confides, "I'm not sure about all this." Which research-based knowledge guides a nurse regarding the emotional factors of pregnancy?
Ambivalence and anxiety about mothering are common. Because mothering is not an inborn instinct in human beings, almost all mothers, including multiparas, report some ambivalence and anxiety about their mothering ability.
A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time?
Infusing oxytocin by piggybacking into the primary line Piggybacking the oxytocin (Pitocin) infusion allows it to be discontinued, if necessary, while permitting the vein to remain open by way of the primary IV.
A client is admitted in preterm labor. After intravenous tocolytic medications are administered, contractions cease and she is discharged. She is to receive oral terbutaline (Brethine) 5 mg every 6 hours at home. When should the nurse advise the client to take the medication?
At mealtime/with food One side effect of terbutaline (Brethine) is nausea and vomiting; to minimize this problem it should be ingested with food.
A client's membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?
Changing the client's position Variable decelerations are usually a result of cord compression; a change of position will relieve the pressure on the cord.
A 37-year-old woman agrees to have a prenatal test done to diagnose fetal defects. There is a history of Down syndrome in her family, and this is her first pregnancy. Which invasive prenatal test provides the earliest diagnosis and rapid test results?
Chorionic villus sampling Chorionic villus sampling may be performed between 10 and 12 weeks' gestation.
The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next?
Determining whether the client feels safe at home Bruising on the backs of back shoulders and both wrists indicates abuse; asking the client whether she feels safe at home will open a dialogue to discuss the possible physical abuse. Whether or not the client admits abuse, the nurse is required to report the finding.
A nurse is observing the electronic fetal monitor as a client in labor enters the second stage. The nurse identifies early decelerations of the fetal heart rate with a return to the baseline at the end of each contraction. What does this usually indicate?
Fetal head compression Early decelerations are expected occurrences as the fetal head passes through the birth canal; the fetal heart rate returns to baseline quickly, indicating fetal well-being.
The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:
Fetal movement In a healthy well-oxygenated fetus the heart rate increases with fetal movement; there should be an acceleration of 15 beats with fetal movement.
The membranes of a client who is at 39 weeks' gestation have ruptured spontaneously. Examination in the emergency department reveals that her cervix is dilated 4 cm and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival?
Introduce the staff nurses to the couple and try to make them feel welcome The client is in the first stage of labor; she and the fetus were assessed earlier, and both are stable. At this time the priority of care is the establishment of a trusting relationship with the client and her partner.
A client is scheduled to have a contraction stress test (CST) to determine fetal well-being. Which type of fetal heart rate (FHR) decelerations constitutes a nonreassuring outcome?
Late The fetus with a borderline cardiac reserve will show hypoxia, evidenced by a decreased FHR with minimal stress, making the test positive
A client in preterm labor is to receive a tocolytic medication, and bedrest is prescribed. Which position should the nurse suggest that the client maintain while on bedrest?
Lateral The lateral position relieves pressure on the vena cava, thereby promoting venous return and increasing placental perfusion.
A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of five pounds since the previous checkup one week ago. The client has delivered and is receiving magnesium sulfate postpartum. The priority during the immediate four hours after delivery would be:
Observing amount of lochia Observing the amount of lochia is a priority during the four hours after delivery because of the risk of hemorrhage, which normally occurs during the fourth stage of labor, and the increased risk of low platelets because of blood clotting issues that accompany preeclampsia.
A primigravida in the first trimester tells a nurse that she has heard that hormones play an important role in pregnancy. Which hormone should the nurse tell the client maintains pregnancy?
Progesterone Progesterone is a female sex hormone, produced by the ovaries and placenta, that prepares the endometrium for implantation of the fertilized ovum, maintains pregnancy, and plays a role in the development of the mammary glands
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?
These accelerations are a sign of fetal well-being. The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive
A nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. What condition is most frequently associated with late decelerations?
Uteroplacental insufficiency Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency
A client having her labor induced with oxytocin has internal fetal monitoring in place. Her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. The baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. The nurse notices that with the last two contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. What type of pattern is this?
Late decelerations Late decelerations begin during the peak of a contraction and continue after the contraction has ended.
A woman with an active lifestyle is in her 30th week of pregnancy. Which activity will the nurse discourage?
Leg lifts and sit-ups
Which drug is used to stop or slow preterm labor?
Magnesium sulfate It is used to stop or slow preterm labor and relax the uterus.
