OB Exam 2

A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?"Which response by the nurse would be most appropriate? A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he's okay."

"He should wet between 6 to 12 diapers each day."

7. A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

"It varies, but you can estimate it returning in about 7 to 9 weeks."

A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Whichstatement by the parents indicates a need for additional teaching? A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the doctor if we notice a funny odor."

"The cord stump should change from brown to yellow."

A nursing instructor is describing the advantages and disadvantages associated with newborn circumcision to a group ofnursing students. Which statement by the students indicates effective teaching? A) "Sexually transmitted infections are more common in circumcised males." B) "The rate of penile cancer is less for circumcised males." C) "Urinary tract infections are more easily treated in circumcised males." D) "Circumcision is a risk factor for acquiring HIV infection."

"The rate of penile cancer is less for circumcised males."

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalpthat crosses suture lines. The nurse documents this finding as: A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma

Caput succedaneum

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. Thenurse documents this finding as which of the following? A) Milia B) Mongolian spots C) Stork bites D) Birth trauma

Mongolian spots

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newbornis experiencing difficulty with oxygenation? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis

Nasal flaring

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation

Respiratory rate 45, irregular

8. A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding?

The client states, "He has my eyes and nose."

11. A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

improves pelvic floor tone

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chestcircumference would be: A) 30 cm B) 32 cm C) 34 cm D) 36 cm

32 cm

20. A nurse is caring for several women in labor. The nurse determines that which woman is the latent phase of labor? A. contractions every 5 minutes, cervical dilation 3 cm B. contractions every 3 minutes, cervical dilation 6 cm C. contractions every 2 1/2 minutes, cervical dilation 8 cm D. contractions every 1 minute, cervical dilation 9 cm

Answer: A Rationale: Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent phase. Contractions every 3 minutes with cervical dilation of 6 cm, contractions every 2½ minutes with cervical dilation of 8 cm, and contractions every 1 minute with cervical dilation of 9 cm suggest the active phase of labor.

7. A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? A. respiratory depression B. urinary retention C. abdominal distention D. hyperreflexia

Answer: A Rationale: Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

3. The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?

Answer: instructing her to apply ice packs to both breasts every other hour

2. When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be

Answer: less than after a vaginal birth. Rationale: Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp

Babinski

After teaching a group of nursing students about variations in newborn head size and appearance, the instructordetermines that the teaching was successful when the students identify which of the following as a normal variation?(Select all that apply.) A) Cephalhematoma B) Molding C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm

Cephalhematoma Molding Caput succedaneum

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level

Decrease the serum bilirubin level

Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a "clunk" when Ortolani's maneuver isperformed. Which of the following would the nurse suspect? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variatio D) Overriding of the pelvic bone

Developmental hip dysplasia

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which ofthe following would the nurse do next? A) Document this as pseudomenstruation B) Notify the practitioner immediately C) Obtain a culture of the discharge D) Inspect for engorgement

Document this as pseudomenstruation

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of smallpapules and is scattered with no pattern. The nurse interprets this finding as which of the following? A) Harlequin sign B) Nevus flammeus C) Erythema toxicum D) Port wine stain

Erythema toxicum

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.) A) Supplementing with iron if the woman is breast-feeding B) Providing supplemental water intake with feedings C) Feeding the newborn every 2 to 4 hours during the day D) Burping the newborns frequently throughout each feeding E) Using feeding time for promoting closeness

Feeding the newborn every 2 to 4 hours during the day Burping the newborns frequently throughout each feeding Using feeding time for promoting closeness

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the bloodsample from the newborn's: A) Finger B) Heel C) Scalp vein D) Umbilical vein

Heel

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birth weight? D) Is acrocyanosis present?

How many hours old is this newborn?

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority? A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment

Hypothermia related to heat loss during birthing process

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A) Just superior to the nipple, at the midsternum B) Lateral to the midclavicular line at the fourth intercostal space C) At the fifth intercostal space to the left of the sternum D) Directly adjacent to the sternum at the second intercostals space

Lateral to the midclavicular line at the fourth intercostal space

The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to apossible problem? A) Limited rugae B) Large scrotum C) Palpable testes in scrotal sac D) Absence of engorgement

Limited rugae

The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythopoiesis C) Enhance bilirubin breakdown D) Promote blood clotting

Promote blood clotting

Just after delivery, a newborn's axillary temperature is 94° C. What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.

Rewarm the newborn gradually.

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side thatwas stroked and begins sucking. The nurse documents which reflex as being positive? A) Palmar grasp reflex B) Tonic neck reflex C) Moro reflex D) Rooting reflex

Rooting reflex

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which of thefollowing would the nurse be least likely to identify as a risk factor for this condition? A) Cesarean birth B) Shortened labor C) Central nervous system depressant during labor D) Maternal asthma

Shortened labor

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additionalteaching because of which of the following? A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib.

Stuffed animals should not be in areas where infants sleep.

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) To aid in maturing the newborn's sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn's respiratory passages

To facilitate maternal-infant bonding

6. When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation?

blood pressure 90/50 mm Hg

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful whenthe parents state which of the following? A) "We can put a tiny bit of lotion on his skin and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair."

"We should avoid using any kind of baby powder."

The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all thatapply.) A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movement E) Absent red reflex

Able to track object to midline Transient deviation of the eyes Involuntary repetitive eye movement

10. Which action is a priority when caring for a woman during the fourth stage of labor? A. assessing the uterine fundus B. offering fluids as indicated C. encouraging the woman to void D. assisting with perineal care

Answer: A Rationale: During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

18. The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase? A. increment B. acme C. peak D. decrement

Answer: A Rationale: Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.

12. When planning the care of a woman in the latent phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? A. every 30 to 60 minutes B. every 60 to 90 minutes C. every 15 to 30 minutes D. every 10 to 15 minutes

Answer: A Rationale: FHR is assessed every 30 to 60 minutes during the latent phase of labor and every 15 to 30 minutes during the active phase. The woman's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after ruptured membranes. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active and transition phases. Contractions are assessed every 30 to 60 minutes during the latent phase and every 15 to 30 minutes during the active phase, and every 15 minutes during transition.

12. A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A. frank B. full C. complete D. footling

Answer: A Rationale: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

22. During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A. "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B. "Since this is your first pregnancy, you can estimate it will be about 10 hours." C. "It will depend on how big the baby is when you go into labor." D. "Time isn't important; your health and the baby's health are key."

Answer: A Rationale: It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last. There is no way to estimate the likely strength and frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the complex fetal rotations needed for an efficient labor will take place properly. All of these factors are unknowns when a woman starts labor. Telling the woman an approximate time would be inappropriate because there is no way to determine the length of labor. It is highly individualized. Although fetal size and maternal and fetal health are important considerations, these responses do not address the woman's concern.

29. A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver? A. Fetal presentation B. Fetal position C. Fetal attitude D. Fetal flexion

Answer: A Rationale: Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. The first maneuver determines presentation; the second maneuver determines position; the third maneuver confirms presentation by feeling for the presenting part; the fourth maneuver determines attitude based on whether the fetal head is flexed and engaged in the pelvis.

28. A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique? A. "Inhale through your nose and exhale through pursed lips." B. "Inhale and exhale through your mouth about 4 times in 5 seconds." C. "Forcefully exhale every so often after inhaling and exhaling through your mouth." D. "Take a cleansing breath before but not after each contraction."

Answer: A Rationale: Many couples learn patterned-paced breathing during their childbirth education classes. Three levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction. In the first pattern, also known as slow-paced breathing, the woman inhales slowly through her nose and exhales through pursed lips. The breathing rate is typically 6 to 9 breaths/min. In the second pattern, the woman inhales and exhales through her mouth at a rate of 4 breaths every 5 seconds. The rate can be accelerated to 2 breaths/sec to assist her to relax. The third pattern is similar to the second pattern except that the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. All breaths are kept equal and rhythmic and can increase as contractions increase in intensity.

18. A nurse is reading a journal article about the various medications used for pain relief during labor. Which drug would the nurse note as producing amnesia but no analgesia? A. midazolam B. prochlorperazine C. fentanyl D. meperidine

Answer: A Rationale: Midazolam is given intravenously and produces good amnesia but no analgesia. It is most commonly used as an adjunct for anesthesia. Prochlorperazine is typically given with an opioid such as morphine to counteract the nausea of the opioid. Fentanyl and meperidine are opioids that produce analgesia.

2. A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. uterus becomes globular B. fetal head at vaginal opening C. umbilical cord shortens D. mucous plug is expelled

Answer: A Rationale: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.

27. A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why." Which response by the nurse would be most appropriate? A. "You had a burst of epinephrine, which is common before labor." B. "You were trying to get everything ready for your baby." C. "You felt your mind telling you that you were about to go into labor." D. "You were looking forward to the birth of your baby."

Answer: A Rationale: Some women report a sudden increase in energy before labor. This is sometimes referred to as nesting because many women will focus this energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household. The increased energy level usually occurs 24 to 48 hours before the onset of labor. It is thought to be the result of an increase in epinephrine (adrenaline) release caused by a decrease in progesterone. The burst of energy is unrelated to getting everything ready, the mind telling the woman that she will be going into labor, or looking forward to the birth.

23. A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis? A. sutures B. fontanelles C. frontal bones D. biparietal diameter

Answer: A Rationale: Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones, along with the parietal and occipital bones are bones of the cranium that are soft and pliable. The biparietal diameter is an important diameter that can affect the birth process.

30. A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include? A. implementing measures for a vaginal birth B. preparing the client for a cesarean birth C. assisting with artificial rupture of the membranes D. instituting continuous internal fetal monitoring

Answer: A Rationale: The fetal presentation and position is left occiput anterior position or LOA, which is the most common and most favorable fetal position for birth. LOA along with right occiput anterior position are optimal positions for vaginal birth. Therefore the nurse should implement measures for a vaginal birth. This fetal presentation is not an indication for cesarean birth. Nor is there need for artificially rupturing the membranes. Continuous internal fetal monitoring would be warranted if the woman or fetus was considered to be high risk.

7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth? A. cesarean B. vaginal C. forceps-assisted D. vacuum extraction

Answer: A Rationale: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

8. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A. latent phase of the first stage. B. active phase of the first stage. C. pelvic phase of the second stage. D. early phase of the third stage.

Answer: A Rationale: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.

13. A nurse palpates a woman's fundus to determine contraction intensity. What would be most appropriate for the nurse to use for palpation? A. finger pads B. palm of the hand C. finger tips D. back of the hand

Answer: A Rationale: To palpate the fundus for contraction intensity, the nurse would place the pads of the fingers on the fundus and describe how it feels. Using the finger tips, palm, or back of the hand would be inappropriate.

19. A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful? A. "We can get up and walk around after receiving combined spinal-epidural analgesia." B. "Higher anesthetic doses are needed for patient-controlled epidural analgesia." C. "A pudendal nerve block is highly effective for pain relief in the first stage of labor." D. "Local infiltration using lidocaine is an appropriate method for controlling contraction pain."

Answer: A Rationale: When compared with traditional epidural or spinal analgesia, which often keeps the woman lying in bed, combined spinal-epidural analgesia allows the woman to ambulate ("walking epidural"). Patient-controlled epidural analgesia provides equivalent analgesia with lower anesthetic use, lower rates of supplementation, and higher client satisfaction. Pudendal nerve blocks are used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. Local infiltration using lidocaine does not alter the pain of uterine contractions, but it does numb the immediate area of the episiotomy or laceration.

2. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? A. Check the fetal heart rate. B. Perform a vaginal exam. C. Notify the primary care provider immediately. D. Change the linen saver pad.

Answer: A Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

26. A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply. A. cervical dilation of 6 cm B. contractions every 2 to 3 minutes C. cervical effacement of 30% D. contractions every 90 seconds E. strong desire to push

Answer: A, B Rationale: During the active phase, the cervix usually dilates from 6 to 10 cm, with 40% to 100% effacement taking place. Contractions become more frequent, occurring every 2-5 min and increase in duration (45 to 60 seconds). Effacement of 30% reflects the latent phase. Contractions occurring every 90 seconds suggest the second stage of labor. A strong urge to push reflects the later perineal phase of the second stage of labor.

15. A nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group identifies which finding as indicating normal fetal acid- base status? Select all that apply. A. sinusoidal pattern B. recurrent variable decelerations C. fetal bradycardia D. absence of late decelerations E. moderate baseline variability

Answer: A, B, C Rationale: Predictors of normal fetal acid-base status include a baseline rate between 110 and 160 bpm, moderate baseline variability, and absences of later or variable decelerations. Sinusoidal pattern, recurrent variable decelerations, and fetal bradycardia are predictive of abnormal fetal acid-base status.

22. Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply. A. walking with partner support B. straddling with forward leaning over a chair C. closed knee-chest position D. rocking back and forth with foot on chair E. supine with legs raised at a 90-degree angle

Answer: A, B, D Rationale: Positioning during the first stage of labor includes walking with support from the partner, side-lying with pillows between the knees, leaning forward by straddling a chair, table, or bed or kneeling over a birthing ball, lunging by rocking weight back and forth with a foot up on a chair or birthing ball, or an open knee-chest position.

14. A nurse is conducting an in-service program for a group of nurses working in the labor and birth suite of the facility. After teaching the group about the factors affecting the labor process, the nurse determines that the teaching was successful when the group identifies which component as part of the true pelvis? Select all that apply. A. pelvic inlet B. cervix C. mid pelvis D. pelvic outlet E. vagina F. pelvic floor muscles

Answer: A, C, D Rationale: The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

21. A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply. A. presence of a support partner B. view of birth as a stressor C. low anxiety level D. fear of loss of control E. participation in a pregnancy exercise program

Answer: A, C, E Rationale: Numerous factors can affect a woman's coping ability during labor and birth. Having the presence and support of a valued partner during labor, engaging in exercise during pregnancy, viewing the birthing experience as a meaningful rather than stressful event, and a low anxiety level can promote a woman's ability to cope. Excessive anxiety may interfere with the labor progress, and fear of labor and loss of control may enhance pain perception, increasing the fear.

17. A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include? Select all that apply. A. internal rotation B. abduction C. descent D. pronation E. flexion

Answer: A, C, E Rationale: The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.

1. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

Answer: At the level of the umbilcus Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus

14. A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: A. normal. B. a possible infection. C. meconium passage. D. transient fetal hypoxia.

Answer: B Rationale: Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

3. When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? A. extent of opening to its widest diameter B. degree of thinning C. passage of the mucous plug D. fetal presenting part

Answer: B Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

5. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? A. intact membranes B. cervical dilation of 2 cm or more C. floating presenting fetal part D. a neonatologist to insert the electrode

Answer: B Rationale: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

13. A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event has most likely occurred? A. cervical dilation B. lightening C. bloody show D. Braxton Hicks contractions

Answer: B Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor. Braxton Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.

4. A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? A. increased energy level with alternating strong and weak contractions B. moderately strong contractions every 4 minutes, lasting about 1 minute C. contractions noted in the front of abdomen that stop when she walks D. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

Answer: B Rationale: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

24. A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which area? A. skin B. muscles of perineal body C. anal sphincter D. anterior rectal wall

Answer: B Rationale: The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second-degree laceration extends through the muscles of the perineal body; a third-degree laceration continues through the anal sphincter muscle; and a fourth-degree laceration also involves the anterior rectal wall.

12. A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A. expectations B. transition to mastery C. reality D. taking-in

Answer: B Rationale: The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.

11. A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group, the nurse determines that the teaching was successful based on which statement by the group? A. The bony pelvis plays a lesser role during labor than soft tissue. B. The pelvic outlet is associated with the true pelvis. C. The false pelvis lies below the imaginary linea terminalis. D. The false pelvis is the passageway through which the fetus travels.

Answer: B Rationale: The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

9. A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted? A. platypelloid B. gynecoid C. android D. anthropoid

Answer: B Rationale: The most favorable pelvic shape for vaginal birth is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth, but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.

25. A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? A. regular contractions B. cervical dilation (dilatation) C. fetal movement through the birth canal D. placental separation

Answer: B Rationale: The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

23. Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor? A. "Lying flat with your head elevated on two pillows makes pushing easier." B. "Choose whatever method you feel most comfortable with for pushing." C. "Let me help you decide when it is time to start pushing." D. "Bear down like you're having a bowel movement with every contraction."

Answer: B Rationale: The role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor, but empowering women to achieve a satisfying experience. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early. Effective pushing can be achieved by assisting the woman to assume a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

16. A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration? A. early decelerations B. variable decelerations C. prolonged decelerations D. late decelerations

Answer: B Rationale: Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns. Early decelerations are visually apparent, usually symmetrical and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes.

10. A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? A. "Call us back when you start having contractions." B. "Come to the clinic or emergency department for an evaluation." C. "Drink 3 to 4 glasses of water and lie down." D. "Come in as soon as you feel the urge to push."

Answer: B Rationale: When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

9. After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching? A. "This type of monitoring is the most accurate method for our baby." B. "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C. "This type of monitoring can only be used after my membranes rupture." D. "You'll be inserting a special electrode into my baby's scalp."

Answer: B Rationale: With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.

21. A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which action would the nurse expect to include when developing a plan of care for this woman? Select all that apply. A. administrating of penicillin G at the onset of labor B. avoiding scalp electrodes for fetal monitoring C. refraining from obtaining fetal scalp blood for pH testing D. administering antiretroviral therapy at the onset of labor E. electing for the use of forceps-assisted birth

Answer: B, C, D Rationale: To reduce perinatal transmission, HIV-positive women are given a combination of antiretroviral drugs. To further reduce the risk of perinatal transmission, ACOG and the U.S. Public Health Service recommend that HIV-infected women with plasma viral loads of more than 1,000 copies per milliliter be counseled regarding the benefits of elective cesarean birth. Additional interventions to reduce the transmission risk would include avoiding use of scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy, encouraging formula feeding after birth, and avoiding invasive procedures such as forceps or vacuum-assisted devices.

20. A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. A. current pregnancy history B. fundal height measurement C. support system D. estimated date of birth E. membrane status F. contraction pattern

Answer: B, E, F Rationale: As part of the admission physical assessment, the nurse would assess fundal height, membrane status, and contractions. Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.

11. When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A. intense B. strong C. moderate D. mild

Answer: C Rationale: A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong or intense contraction feels like the forehead.

30. A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? A. Check the pH to ensure the fluid is amniotic fluid. B. Prepare to administer an antibiotic. C. Notify the health care provider about possible meconium. D. Check the maternal heart rate.

Answer: C Rationale: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A. "I'm feeling contractions mostly in my back." B. "My contractions are about 6 minutes apart and regular." C. "The contractions slow down when I walk around." D. "If I try to talk to my partner during a contraction, I can't."

Answer: C Rationale: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

29. Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A. -2 B. -1 C. 0 D. +1

Answer: C Rationale: Fetal engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.

15. A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use? A. flexion B. extension C. longitudinal D. cephalic

Answer: C Rationale: Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are three primary lies: longitudinal, oblique, and transverse. Flexion and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal presentation.

6. A client has not received any medication during her labor. She is having frequent contractions about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A. latent phase of the first stage of labor. B. perineal phase of the first stage of labor. C. late active phase of the first stage of labor. D. early phase of the third stage of labor.

Answer: C Rationale: Late in the active phase of labor, contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies (moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in the serious work of her labor. She limits interactions with those in the room. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of the second stage is the period of active pushing. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta

1. A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A. butorphanol B. fentanyl C. naloxone D. promethazine

Answer: C Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.

25. A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next? A. suctioning of the mouth and nose B. clamping of the umbilical cord C. checking for the cord around the neck D. drying of the newborn

Answer: C Rationale: Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. Then the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium. Finally the umbilical cord is double-clamped and cut between the clamps. The newborn is placed under the radiant warmer, dried, assessed, wrapped in warm blankets, and placed on the woman's abdomen for warmth and closeness.

26. A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. boggy, soft uterus B. uterus becoming discoid shaped C. sudden gush of dark blood from the vagina D. shortening of the umbilical cord

Answer: C Rationale: Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.

24. Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A. -2 B. -1 C. 0 D. +1

Answer: C Rationale: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations.

27. A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds? A. At the level of the woman's umbilicus B. In the area above the woman's umbilicus C. In the woman's lower abdominal quadrant D. At the upper outer quadrant of the woman's abdomen

Answer: C Rationale: The fetal heart rate is heard most clearly at the fetal back. In a cephalic presentation, the fetal heart rate is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

3. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A. +2 station. B. 0 station. C. -2 station. D. crowning.

Answer: C Rationale: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

16. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? A. occiput B. face C. buttocks D. shoulder

Answer: C Rationale: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation.

8. When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR? A. over the uterine fundus where contractions are most intense B. above the umbilicus toward the right side of the diaphragm C. between the umbilicus and the symphysis pubis D. between the xiphoid process and umbilicus

Answer: C Rationale: The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

5. A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A. supine B. lithotomy C. upright D. knee-chest

Answer: C Rationale: The use of any upright position helps to reduce the length of labor. Research shows that women who assumed the upright position during the first stage of labor experienced significant improvement in the progress of labor, faster fetal head descent, significant reduction of pain, and a good Apgar score. Additionally, studies show that recumbent positions result in supine hypotension, diminishing uterine activity and reducing the dimensions of the pelvic outlet. The knee-chest position would assist in rotating the fetus in a posterior position.

28. A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor and the passage of the fetus through the birth canal. As part of the class, the nurse explains that specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse identify as being most important in affecting the birth process? Select all that apply. A. Occipitofrontal B. Occipitomental C. Suboccipitobregmatic D. Biparietal E. Diagonal conjugate

Answer: C, D Rationale: The diameter of the fetal skull is an important consideration during the labor and birth process. Fetal skull diameters are measured between the various landmarks of the skull. Diameters include occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal. The two most important diameters that can affect the birth process are the suboccipitobregmatic (approximately 9.5 cm at term) and the biparietal (approximately 9.25 cm at term) diameters. Diagonal conjugate is a measure of the pelvic inlet of the mother.

10. A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A. shapeless. B. circular. C. triangular. D. slit-like.

Answer: D Rationale: After birth, the external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

4. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: A. yellow. B. olive green. C. pink. D. blue.

Answer: D Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.

19. A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction? A. heart rate increase from 76 bpm to 90 bpm B. blood pressure rise from 110/60 mm Hg to 120/74 C. white blood cell count of 12,000 cells/mm3 D. respiratory rate of 10 breaths/minute

Answer: D Rationale: During labor, the mother experiences various physiologic responses including an increase in heart rate by 10 to 20 bpm, a rise in blood pressure by up to 35 mm Hg during a contraction, an increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma, and an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism. A drop in respiratory rate would be a cause for concern.

17. A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse most likely use when explaining this measure? A. "This technique focuses on manipulating body tissues." B. "The technique requires focusing on a specific stimulus." C. "This technique redirects energy fields that lead to pain." D. "The technique involves light stroking of the abdomen with breathing."

Answer: D Rationale: Effleurage involves light stroking of the abdomen in rhythm with breathing. Therapeutic touch is an energy therapy and is based on the premise that the body contains energy fields that lead to either good or ill health and that the hands can be used to redirect the energy fields that lead to pain. Attention focusing and imagery involve focusing on a specific stimulus. Massage focuses on manipulating body tissues.

6. A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A. "The warmth and buoyancy of the water has a nice relaxing effect." B. "I can stay in the bath for as long as I feel comfortable." C. "My cervix should be dilated more than 5 cm before I try using this method." D. "The temperature of the water should be at least 105? (40.5?)."

Answer: D Rationale: Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105? (40.5?) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.

4. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?

Answer: cannot be palpated Rationale: By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of thefollowing would the nurse do first? A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe.

Aspirate the oral and nasal pharynx with a bulb syringe.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine.

Assess the newborn for signs of respiratory distress.