NURS 351 exam 2 Review prepu
A nurse is explaining the fetus's position to a female client whose baby is in the frank breech position. Which statement by the client would indicate that the teaching was understood?
"My baby's hips are flexed, and the knees are extended." Rationale: The frank breech position of the fetus indicates that the sacrum is the presenting part. The hips are flexed, and the knees are extended. Complete breech is when both the hips and knees are flexed and the sacrum is presenting. Kneeling breech is when the hips are extended, and the knees are flexed. Footling breech is when both the hips and knees are extended so that the fetus presents feet first.
A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?
Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.
The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every 2 hours to detect which condition?
pulmonary edema In the hospital, monitor blood pressure at least every 4 hours for mild preeclampsia and more frequently for severe disease. In addition, it is important to auscultate the lungs every 2 hours. Adventitious sounds may indicate developing pulmonary edema.
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman. Rationale: Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?
Massage the woman's back.
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
increasing birth weight. shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births.
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?
Have the client pant and blow through the contraction. The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.
The nurse is caring for a multigravid who experienced a placental abruption 4 hours ago. For which potential situation will the nurse prioritize assessment?
Uterine atony A placental abruption (abruptio placentae) may occur any time before and during the labor process. After delivery, the woman who has had an abruption requires close monitoring for postpartum hemorrhage because of the risk for uterine atony. This does not cause increased blood pressure or blood incompatibilities.
Patterned breathing techniques used in labor provide which benefits? Select all that apply. conscious relaxation distraction pain relief without special tools spirituality
distraction pain relief without special tools
A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?
gestational hypertension Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Placental abruption (abruptio placentae), a separation of the placenta from the uterine wall; placenta previa (placenta covering the cervical os); and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.
A nurse is teaching a group of pregnant woman about bleeding that can occur early in pregnancy. The nurse determines that additional teaching is needed when the group identifies which condition as a common cause?
placenta previa The three most common causes of hemorrhage during the first half of pregnancy are spontaneous abortion (miscarriage), ectopic pregnancy, and GTD. Placenta previa occurs in the later weeks of gestation.
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:
"I may end up with a severe headache from the spinal anesthesia." Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache.
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?
"It distracts your brain from the sensations of pain." Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.
A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?
"The antibodies may be those transferred across the placenta; the baby may not develop AIDS." Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.
A 25-year-old pregnant client comes to the office for the first prenatal visit. During the history, the client tells the nurse she had tuberculosis 5 years ago. What is the nurse's best response?
"You will have to maintain an adequate level of calcium during your pregnancy." A client who had tuberculosis earlier in life must be especially careful to maintain an adequate level of calcium during pregnancy to ensure the calcium tuberculosis pockets in her lungs are not broken down and the disease is not reactivated. The tuberculosis may reoccur if the intra-abdominal pressure (from pushing) breaks the calcified pockets open; if the woman is positive for active tuberculosis she will have to take isoniazid (INH), rifampin (RIF), and ethambutol HCL, and if the woman has a positive reaction, a chest X-ray or a sputum culture is needed to confirm the diagnosis.
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?
"Your primary care provider will order safe doses of your medication." Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.
The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh:
4,000 g to 4500 g Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.1 to 9.9 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions
The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?
6.5 rationale: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.
A pregnant woman with diabetes is having her hemoglobin (glycosylated) level evaluated. The nurse determines that the woman's glucose is under control and continues the woman's plan of care based on which result?
6.5% Rationale: A hemoglobin (glycosylated) level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. A glycosylated hemoglobin level less than 7% indicates that the plan is working and should be continued.
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?
A dipstick value of 2+ for protein The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?
Ambulate only with assistance from the nurse or caregiver. rationale: The client may have decreased sensory ability from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
Assess for labor progression. Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. However, the best first step is to assess the client for labor progress before assisting her otherwise. Bearing down can be a sign that the client is 10 cm dilated.
After conducting a refresher class on possible congenital infections with a group of perinatal nurses, the nurse recognizes the class was successful when the group identifies which congenital viral infection as the most common?
CMV Cytomegalovirus (CMV) is the most common congenital and perinatal viral infection in the world. Human immunodeficiency virus (HIV), human papillomavirus (HPV), and herpes simplex virus (HSV) are other potential viruses.
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize?
Check the chart for the last void. The most probable explanation of the mass is a full bladder. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be handled by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.
A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?
Endorphins The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.
The nurse is assessing the external fetal monitor and notes the following: fetal heart rate of 175 beats/min, decrease in variability, and late decelerations. Which action should the nurse tale first?
Have the client change position. Rationale Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the client to change position to see if that will take the pressure off the cord. The health care provider should be notified, especially if a change of position is ineffective. The nurse should continue to monitor the pattern continuously until the situation is changed and to evaluate the effectiveness of interventions. This could be an ominous sign indicating the need for further interventions to include cesarean birth.
A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?
Lie on her side so she is comfortable.
The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record?
Precipitous labor A labor that is less than 3 hours in duration is a precipitous labor. Prolonged labor, also known as failure to progress, occurs when labor lasts for approximately 20 hours or more in a first-time mother. Prodromal labor is labor that starts and stops before fully active labor begins. The contractions are real, but they come and go, and labor does not progress. False labor is intermittent nonproductive or practice contractions, which most commonly occur in the last 2 months before a full-term delivery.
A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?
Prevent maternal seizures The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.
A woman with known cardiac disease is in labor. In what position would the nurse place the client?
Semi-recumbent with a pillow under one hip Rationale: A laboring mother with known cardiac disease needs to be positioned in a semi-recumbent position and have a wedge or pillow placed under one hip. A cardiac client is never placed in a supine position because being flat on the back can lead to supine hypotensive syndrome, which leads to decreased placental perfusion and can increase the maternal cardiac output. Sitting straight up may be uncomfortable for the mother. Trendelenburg is definitely a wrong position due to the abdomen pressing against the diaphragm; it is also counter to the natural position of the uterus down toward the cervix.
The pain of labor is influenced by many factors. What is one of these factors?
The woman is prepared for labor and birth. The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms: -acute respiratory distress, -cyanosis, -hypotension.
The clinic nurse teaches a client with pregestational type 1 diabetes that maintaining a constant insulin level is very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:
an insulin pump Rationale: Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully the client maintains diet and balances exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.
A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum?
assessing for cardiac decompensation The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks' gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.
A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?
cesarean birth If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD
A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition?
cytomegalovirus rationale: The nurse would be alert for the development of cytomegalovirus infection. Pregnant women acquire active disease primarily from sexual contact, blood transfusions, kissing, and contact with children in day care centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breastfeeding. Chlamydia, gonorrhea, and toxoplasmosis are not spread through contact with children in day care centers.
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?
decreased alertness Rationale: Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:
effleurage Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.
A woman at 9 weeks' gestation was unable to control the nausea and vomiting of hyperemesis gravidarum through conservative measures at home. With nausea and vomiting becoming severe, the woman was omitted to the obstetrical unit. Which action should the nurse prioritize?
establish IV for rehydration With severe nausea and vomiting the client may be dehydrated upon coming to hospital for assistance, so establishing an IV line is the priority intervention. This will also allow for hydration, and if needed, the administration of an antiemetic to bypass the gastrointestinal tract. Although the nurse will explain the NPO status to the client (so that vomiting may be brought under control) and the likelihood of being placed on bed rest with bathroom privileges, these teachings are not the priority.
A nurse is providing care to a pregnant woman with preterm prelabor rupture of membranes (PPROM). On admission, the client's baseline information was as follows: temperature, 97.6°F (36.5°C); pulse, 76 beats/minute; fetal heart rate, 136 beats/minute; white blood cell count, 7 x 103cells/mm3 (7.0 x 109/L). Now, 8 hours later, assessment reveals the following: temperature, 99.6°F (37.7°C); pulse, 82 beats/minute; fetal heart rate, 180 beats/minute; white blood cell count, 8.5 x 103 cells/mm3 (8.5 X 109/L). The nurse suspects a possible infection based on the change in which parameter?
fetal heart rate Nursing management for the woman with prelabor rupture of membranes (PROM) or preterm prelabor rupture of membranes (PPROM) focuses on preventing infection and identifying uterine contractions. The risk for infection is great because of the break in the amniotic fluid membrane and its proximity to vaginal bacteria. Therefore, maternal vital signs must be monitored closely. The nurse should be alert for a temperature elevation or an increase in pulse, which could indicate infection. Also the nurse will monitor the fetal heart rate continuously, reporting any fetal tachycardia (which could indicate a maternal infection). The nurse will evaluate the results of laboratory tests such as a complete blood count (CBC). An elevation in white blood cells would suggest infection. For this woman, the change in fetal heart rate is significant and suggests a possible infection. Although the temperature, pulse rate, and white blood cell count are slightly increased, they are still within acceptable limits. Concern would grow if the client's temperature increased above100.4°F (38°C), pulse rate rose significantly from baseline, or the white blood cell count rose above 10 x 103 cells/mm3 (10 x 109/L).
A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?
identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).
A pregnant woman diagnosed with cardiac disease 4 years ago is told that her pregnancy is a high-risk pregnancy. The nurse then explains that the danger occurs primarily because of the increase in circulatory volume. The nurse informs the client that the most dangerous time for her is when?
in weeks 28 to 32 Rationale: The danger of pregnancy in a woman with cardiac disease occurs primarily because of the increase in circulatory volume. The most dangerous time for a woman is in weeks 28 to 32, just after the blood volume peaks.
A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?
lower quadrant of the maternal abdomen
A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn?
microcephaly Signs that are likely to be present in the 10% of newborns who are symptomatic at birth include microcephaly, seizures, IUGR, hepatosplenomegaly, jaundice, and rash.
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?
prevent maternal D antibody formation. Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
During the assessment of a laboring client, the nurse learns that the client has cardiovascular disease (CVD). Which assessment would be priority for the newborn?
respiratory function rationale: The nurse should identify respiratory distress syndrome as a major risk that can be faced by the offspring of a client with cardiovascular disease. While the other assessments are important, they are not priority
A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth?
the viral load A woman who has HIV during pregnancy is at risk for transmitting the infection to the fetus during pregnancy or childbirth and to the newborn while breastfeeding. The type of birth, vaginal or cesarean, depends on several factors, including the woman's viral load, use of ART during pregnancy (not waiting until the birth), length of time membranes have been ruptured, and gestational age (not mother's age). With prenatal ART and prophylactic treatment of the newborn, there is a reduced risk of perinatal HIV transmission. The amniocentesis results would not be a factor in preventing the spread of HIV to the infant and may actually lead to the fetus being infected through the puncture site and bleeding into the amniotic sac.