Nurse 140 Maternity Ch. 6

What would the nurse expect a normal finding to be during assessment of the fundus of the uterus every 15 minutes during the fourth stage of labor? 1. Firm and at the umbilicus 2. Soft and deviated to the left 3. Firm and deviated to the right 4. Soft to touch, but firm with massage

1. Firm and at the umbilicus During the fourth stage, recovery of labor, the uterus is normally found firmly contracted at or below the umbilicus level. Deviation to the right can indicate a full bladder. A boggy or soft uterus can indicate a potential complication. The uterus is not usually found deviated to the left. REF: p. 156 Table 6-6

What signs of respiratory distress in the neonate should be reported immediately? (Select all that apply.) 1. Grunting respirations 2. Flaring of the nostrils 3. Heart rate above 110 beats/minute 4. Cyanosis of the hands and feet 5. Respiratory rate higher that 60 breaths/minute

1. Grunting respirations 2. Flaring of the nostrils 5. Respiratory rate higher that 60 breaths/minute Some signs of respiratory distress that should be immediately reported include grunting respirations, persistent cyanosis (other than hands and feet), flaring of the nostrils, retractions, sustained respiratory rate higher than 60 breaths/minute, and sustained heart rate greater than 160 beats/minute or less than 110 beats/minute. REF: p. 158 Awarded 0.0

If the sacrum of the fetus in a breech presentation is in the mother's right posterior pelvis, it is described as 1. right sacrum posterior. 2. left mentum anterior. 3. transverse. 4. left occiput posterior.

1. right sacrum posterior. The first word refers to what side of the mom's pelvis the presenting part is facing, the second is the fetal reference point (occiput for vertex presentations, mentum for face, and sacrum for breech), and the third references the front (anterior) or back (posterior) of the mother's pelvis. If the fetus is neither anterior nor posterior, then it is transverse. REF: p. 129

Which statement made by an expectant mother demonstrates understanding of the significant risks of home delivery? 1. "I know I will have access to the technology that monitors my well-being." 2. "I know that there will be a delay in emergency care if there is a complication." 3. "The physician will only come to my home if I have a complication." 4. "The midwife can perform most emergency procedures at home."

2. "I know that there will be a delay in emergency care if there is a complication." Mothers will not have access to technology at home. Most physicians will not come to the home for medical care. Most emergency procedures can only be performed in the hospital per standard of care. It is important that this mother understands that there will be a delay, creating significant risk, if there is a complication. REF: p. 125

What is the purpose of the administration of vitamin K (AquaMephyton) to a newborn? 1. Cord healing 2. Blood clotting 3. Respiratory status 4. Infection prevention

2. Blood clotting Vitamin K (AquaMephyton) is required by the newborn to assist in blood clotting. A newborn lacks vitamin K at birth because of a sterile gastrointestinal tract. Newborns receive a single dose of vitamin K into the vastus lateralis muscle before leaving the delivery room, usually at age 1 hour. REF: p. 160

Which is a sign of imminent birth? 1. Increased vaginal discharge 2. Baby dropping 3. Grunting sounds 4. Diarrhea

3. Grunting sounds Sitting on one buttock, making grunting sounds, bearing down with contractions, stating "the baby is coming", and bulging of the perineum are all signs of imminent birth and the nurse should not leave the patient. REF: p. 135|Skill 6-1

Which nursing action has the highest priority for a patient in the second stage of labor? 1. Check the fetal position. 2. Administer pain medication. 3. Help the mother push effectively. 4. Prepare the mother to breastfeed on the delivery table.

3. Help the mother push effectively. The second stage of labor is the pushing stage. The nurse should help the mother push effectively. The mother cannot breastfeed in the second stage of labor. Checking fetal position is not the highest priority during the second stage of labor. Pain medication should not be administered in the second stage because it will cause a lethargic neonate and possibly depress the newborn's respirations. REF: p. 155

When 3 to __________________ cm of the fetal head is visible at the vaginal opening, this is known as crowning.

4 cm

At what point during the labor process does the health care provider know that the second stage of labor has begun? 1. The fetus is at +1 station. 2. The placenta is delivered. 3. The woman feels the urge to push. 4. The cervix is fully dilated at 10 cm.

4. The cervix is fully dilated at 10 cm. Stage 2 is from full dilation of the cervix until birth of the fetus. Pushing before full dilation can be dangerous to the fetus and exhausting to the mother. The +1 station is too high. Delivery of the placenta is stage 3. REF: p. 155

The physician performs a nitrazine paper test and the nurse observes the strip paper to be deep blue in color. What is the significance of this assessment? 1. The woman is at risk for placenta previa. 2. The woman is in the active phase of labor. 3. The fluid is acidic and is most likely urine. 4. The fluid is alkaline and most likely amniotic fluid.

4. The fluid is alkaline and most likely amniotic fluid. A blue-green or deep blue color of the nitrazine paper indicates the fluid is alkaline and most likely amniotic fluid. A yellow to yellow-green color of the strip paper indicates the fluid is acidic and is most likely urine. The nitrazine paper test does not indicate stage of labor nor can it identify placenta previa. REF: p. 144

Excessive anxiety and fear during labor may result in a(n) 1. ineffective labor pattern 2. abnormal fetal presentation or position 3. release of oxytocin from the pituitary gland 4. rapid labor and uncontrolled birth

ANS: 1 Anxiety can increase a woman's perception of pain and reduce her tolerance of it. Anxiety and fear also cause the secretion of stress compounds from the adrenal glands. These compounds, called catecholamines, inhibit uterine contractions and divert blood flow from the placenta. REF: The psyche

A woman in active labor has contractions every 3 minutes lasting 60 seconds, and her uterus relaxes between contractions. The electronic fetal monitor shows the FHR reaching 90 beats/min for periods lasting 20 seconds during a uterine contraction. The appropriate priority nursing actions is to: 1. continue to monitor closely. 2. administer oxygen by mask at 10L/min 3. notify the health care provider 4. prepare for a cesarean section

ANS: 1 Contractions every 3 minutes that last 60 seconds, a uterus that relaxes between contractions, and an FHR of 90 beats/minute that lasts 20 seconds during a uterine contraction all describe early decelerations, which result from compression of the fetal head and are a reassuring sign of fetal well-being. REF: Evaluating fetal heart patterns

A laboring women suddenly begins making grunting sounds and bearing down during a strong contraction. The nurse should initially: 1. leave the room to find an experienced nurse to asses the woman 2. look at her perineum for increased bloody show or perineal bulging. 3. ask her if she needs pain medication 4. tell her that these are common sensations in late labor

ANS: 2 Grunting sounds and bearing down suggest that the woman is about to give birth. The nurse must stay with the woman and observe for other signs of impending birth, such as increased bloody show or perineal bulging, as well as monitor maternal and fetal well-being. The nurse may use the call bell to summon assistance or request the physician. REF: Impending birth

The nurse is caring for a woman in labor. Which of the following observation require immediate nursing intervention? a. FHR 90 beats/min between contraction b. maternal tachsystole c. contractions lasting 60 seconds with an interval of 90 seconds d. FHR baseline variability 1. b & c 2. a & d 3. a & b 4. c & d

ANS: 3 Fetal heart baseline variability is normal and contractions lasting 60 seconds with an interval of 90 seconds allow for adequate fetal circulation, and no change in nursing care is indicated. A FHR below 110 indicates fetal distress and maternal tachysystole indicates the uterine contractions are compromising fetal circulation and both require immediate intervention. REF: Monitoring the woman

To determine the frequency of uterine contractions, the nurse should note the time from the: 1. beginning to end of the same contraction 2. end of one contraction to the beginning of the next contraction 3. beginning of one contraction to the beginning of the next contraction 4. contraction's peak until the contraction begins to relax

ANS: 3 Frequency is the time it takes from the beginning of one contraction to the beginning of the next contraction. Duration is from the beginning to the end of the same contraction. Interval is from the end of one contraction to the beginning of the next contraction. REF: Uterine contractions

A women who is pregnant with her first child phones an intrapartum facility and says her "water broke". The nurse should her to: 1. wait until she has contractions every 5 minutes for 1 hour. 2. take her temperature every 4 hours and come to the facility if it is over 38C (100.4F) 3. come to the facility promptly, but safely 4. call an ambulance to bring her to the facility

ANS: 3 When the amniotic sac ruptures, infection can become more likely if many hours elapse between the rupture of membranes and birth. In addition, the umbilical cord may slip down and become compressed. For these reasons, women should go to the birth facility when their membranes rupture, even if there are no other signs of labor. REF: Admission to the hospital or birth center