OB Exam 2
The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment?
Check for deep vein thrombosis.
Dick-Read childbirth education
Classes focus on breathing to prevent the fear-tension-pain cycle
Which statement is incorrect regarding prepared childbirth education?
No use of anesthetics or drugs is to be administered to clients so they can have a natural childbirth experience.
Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor?
Dick-Read
Which interventions are required following an amniotomy procedure? (Select all that apply.)
a. Notation related to amount of fluid expelled b. Color and consistency of fluid c. Fetal heart rate
Which vaccinations are indicated for the postpartum client if she does not have immunity? (Select all that apply.)
a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap)
Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?
Client has received an epidural for pain control during the labor process.
The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding?
Contact the health care provider.
What is covered by early pregnancy classes offered in the first and second trimesters?
Coping with common discomforts of pregnancy
The nurse is reviewing the option of childbirth classes with a patient in her second trimester. Which statement indicates to the nurse that the patient has understood the teaching?
I will likely be more satisfied with my labor if I go to classes.
The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase?
The client is requesting pain medication.
When reading a new clients birth plan, the nurse notices that the client will be bringing a doula to the hospital during labor. What does the nurse think that this means?
The client will bring a paid, trained labor support person with her during labor.
Lamaze childbirth education
Psychoprophylaxis class that uses the mind to prevent pain
The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places.
0.75mL
The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?
18-gauge
The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
Firm fundus, but excessive lochia
Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?
Flexion
Which documentation in the clients chart on the 14th postpartum day indicates a normal involution process?
Fundus below the symphysis and not palpable
To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform?
Gently palpate, applying the same technique used for vaginal deliveries.
The postpartum nurse is administering ibuprofen (Advil) to a client with episiotomy discomfort. The prescribed order is 400 mg of Advil by mouth every 6 to 8 hours PRN for discomfort. The Advil sent by the pharmacy is 200 mg/tablet. How many tablet(s) should the nurse administer to the client? Record your answer as a whole number.
2 Tablets
Which client is most likely to experience pain during labor?
Gravida 2 who is anxious because her last labor was difficult
Which client at term should go to the hospital or birth center the soonest after labor begins?
Gravida 3, para 2, whose longest previous labor was 4 hours
Which client could safely be cared for by a certified nurse-midwife?
Gravida 3, para 2, with no complications
Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic?
Gravida 5, para 5
The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount?
4- to 6-inch stain on the peripad
The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions?
Assess from the beginning to the end of each contraction.
At 5 minutes after birth, the nurse assesses that the neonates heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign?
8
A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long?
8 to 10 hours
At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. The Apgar score for this infant is:
9.
The health care provider has asked the nurse to prepare for an amniotomy. What is the nurses priority action with this procedure?
Assess the fetal heart rate immediately after the procedure.
Which maternal factor may inhibit fetal descent?
A full bladder
Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)
A gush of blood appears. The uterus rises upward in the abdomen. The cord descends further from the vagina.
A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply)
A. Ask her if her if she thinks that her membranes have ruptured. E. Tell her to come into the hospital for evaluation.
A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?
Auscultate anterior and posterior breath sounds.
The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed?
If I breastfeed and supplement with formula, I wont need any birth control.
A client whose cervix is dilated to 5 cm is considered to be in which phase of labor?
Active phase
A pregnant client is anticipating a vaginal birth without complications. During the course of her labor, complications arise and the fetus has to be delivered via cesarean section. The client is visibly upset and wants to know why this has happened to her because she did everything right during her pregnancy. Which priority nursing diagnosis would apply?
Anxiety
Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?
Anxiety related to imminent birth process
Which assessment finding would cause a concern for a client who had delivered vaginally?
Client complains of fingers tingling
Which clinical findings would be considered to be normal for a preterm fetus during the labor period?
Baseline tachycardia
The Centers for Disease Control and Prevention (CDC) recommends the use of which personal protective equipment with which the nurse is likely to come into contact?
Blood and blood products
The health care provider for a laboring patient makes the following entry into the patients record: 3/50%/1. What instruction will the nurse implement with the patient?
Breathe with me slowly, in through your nose and out through your mouth.
A client asks, What can I do to help decrease the amount of pain with labor? What should be the nurses best response?
By trying to relax, the contractions will be more efficient and the pain may be less.
Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history?
Client has a history of pregnancy.
Which event is the best indicator of true labor?
Cervical dilation and effacement
The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?
Clear with bits of vernix caseosa
During the course of labor, a client has been having her labor coach rub her lower back to relieve pain. After 30 minutes, the client complains that this method is no longer working and becomes increasingly frustrated with the labor coach. The vaginal exam is 2 to 3 cm, 80% effaced, and 1 station, membranes intact. Which option would you recommend to decrease the clients perceived pain?
Have the labor coach change the touch location and begin gently massaging another area on the back.
Which is an essential part of nursing care for a laboring client?
Helping the woman manage the pain
The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction?
Diminishes as the spiral arteries are compressed
The support person for your labor client has been applying gentle massage to the clients upper back frequently over the past hour. Now, the labor client states that it just isnt helping anymore. Both the support person and labor client are becoming frustrated with each others inability to make things less stressful during the labor process. What would be the best nursing response at this time?
Discuss the effects of habituation and suggest alternate measures that could be used to relieve pain.
If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which?
Distended bladder
The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding?
Document the finding in the patients chart.
If the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take?
Document the finding.
The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?
Document this evidence of normal early maternal-infant attachment behavior.
The labor nurse is reviewing breathing techniques with a primipara admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
During labor, when she can no longer talk through contractions
Which is the best measure to prevent abdominal distention following a cesarean birth?
Early and frequent ambulation
Which type of cutaneous stimulation involves massage of the abdomen?
Effleurage
Which assessment finding could indicate hemorrhage in the postpartum patient?
Elevated pulse rate
The nurse examines a primiparas cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurses priority action?
Encourage the patient to exhale in short breaths with contractions.
The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take?
Encourage the use of an incentive spirometer.
Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
Engagement
A gravida 1, para 0, 38 weeks gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, 1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?
Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.
The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?
Every 30 minutes
A laboring patient states to the nurse, I have to push! What is the next nursing action?
Examine the patients cervix for dilation.
If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included?
Explanation of the risks of becoming pregnant within 28 days following injection
The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the clients record?
Fetal heart rate
A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.)
In true labor, the cervix begins to dilate. In true labor, contractions often resemble menstrual cramps during early labor. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.
Bradley childbirth education
Includes the father as a support person and a coach
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?
Inform the mother that the rate is normal.
Which of the following would indicate an abnormal finding during the postpartum period?
Lochia flow changing from alba to rubra
Which maternal event is abnormal in the early postpartal period?
Lochial color changes from rubra to alba
The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions?
Maternal circulating blood volume increases temporarily during contractions.
Which should the nurse recognize as being associated with fetal compromise?
Meconium-stained amniotic fluid
Rho(D) immune globulin will be ordered postpartum if which situation occurs?
Mother Rh-negative, baby Rh-positive
The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.)
Natural oxytocin in conjunction with other substances plays a role. Stretching, pressure, and irritation of the uterus and cervix increase.
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
No swelling or edema to the perineal area
The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
Offer the client a warm blanket. Place an ice pack on the perineum. Massage the uterus if it is boggy.
The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient?
On her left side
In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth?
Pain management techniques
On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?
Perform a vaginal exam to denote progress.
The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?
Place a small pillow under the patients left hip.
After birth of the placenta the patient states, All of a sudden I feel very cold. What is the best nursing action in response to this statement?
Place a warm blanket over the patient.
Postpartal overdistention of the bladder and urinary retention can lead to which complication?
Postpartum hemorrhage and urinary tract infection
The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
Powers Passage Passenger Psyche
A primipara client asks about possible support options for her during the labor process. She is apprehensive that her family members will not be prepared to assist her during this time. Which option would be most effective for this client?
Provide information to the client about obtaining a doula during the labor process.
Which comfort measure should a nurse use to assist a laboring woman to relax?
Recommend frequent position changes.
The gynecologist performs an amniotomy. What will the nurses role include immediately following the procedure?
Recording the character and amount of amniotic fluid
Martha is a gravida 3, para 2, whose last child was born 5 years ago. She attended childbirth preparation classes with her first pregnancy. Which class would be most appropriate for her?
Refresher course
Positioning
Relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis
Which phrase best describes neuromuscular dissociation?
Relaxing the rest of the body while one group of muscles is strongly contracted
The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the babys head?
Restitution
The nurse assesses a patient in active labor and determines that the fetus is in the left occiput posterior position. The patient indicates to the nurse that she does not want an epidural. Which is the best technique for the nurse to include in the patients plan of care?
Sacral pressure
Which technique would provide the best pain relief for a pregnant woman with an occiput posterior position?
Sacral pressure
The nurse assess a laboring patients contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern?
Stage 1, active phase
What does a birth plan help the parents accomplish?
Taking an active part in planning the birth experience
To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care?
Teach the client to do pelvic floor exercises to combat potential stress incontinence.
The primipara at 39 weeks gestation states to the nurse, I can breathe easier now. What is the nurses best response?
That process is called lightening. Do you have to urinate more frequently?
A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
The acme
Presentation
The fetal part that enters the pelvic inlet first
Which fundal assessment finding at 12 hours after birth requires further assessment?
The fundus is palpable two fingerbreadths above the umbilicus.
Fetal lie
The orientation of the long axis of the fetus to the long axis of the woman
The birth educator is discussing the advantages and disadvantages of birthing options. Which disadvantage is common with epidural anesthesia?
The use of forceps and oxytocin administration is increased.
Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth?
The vulva bulges and encircles the fetal head.
A postpartum client asks, Will these stretch marks go away? Which is the nurses best response?
They will fade to silvery lines but wont disappear completely.
A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client?
This results from molding.
The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?
To determine cervical dilation and effacement
The nurse is preparing to perform Leopolds maneuvers. Why are Leopolds maneuvers used by practitioners?
To determine the best location to assess the fetal heart rate
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
Uterine fundus 2 cm above the umbilicus
In a prenatal education class, the nurse is reviewing the importance of using relaxation techniques during labor. Which client statement will the nurse need to correct?
We will practice relaxation techniques only in a quiet setting so I can focus.
A postpartum client overhears the nurse tell the health care provider that she has a positive Homans sign and asks what it means. Which is the nurses best response?
You have calf pain when the nurse flexes your foot.
A client at 40 weeks gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:
a trickle of fluid from the vagina.
The nurse is teaching a nonbreastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.)
a. Avoid massaging the breasts. d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.
The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.)
a. I will gently pat the perineum dry rather than wipe. d. I will use the perineal bottle without touching the perineum.
A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)
a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time
The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)
a. Maternal hypotension c. Meconium-stained amniotic fluid d. Maternal fever38 C (100.4 F) or higher
The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.)
a. Sitz baths four times a day c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours
The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)
a. Soft boggy uterus c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics
The prenatal nurse educator is teaching couples the technique of using sacral pressure during labor. Which should be included in the teaching session? (Select all that apply.)
a. The technique can be combined with heat to the area. c. Tennis balls may be used to apply the pressure to the sacral area. e. The hand may be moved slowly or remain positioned directly over the sacrum.
A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception is:
assisting the client in breathing methods aimed at taking control of pain perception based on the contraction pattern.
The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that hes doing now, he could tell her when the contractions are:
at their acme.
Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.)
b. Dry the infant off with sterile towels. c. Place stockinette cap on infants head. e. Remove wet linen as needed.
The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.)
b. Feeling of pelvic fullness d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision
When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.)
b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done.
The nurse decides to perform a prescribed PRN intermittent sterile catheterization on a postpartum client if which occurs? (Select all that apply.)
b. The fundus is displaced from the midline and the client has been unable to void. d. The amount voided is less than 150 mL and the fundus is displaced from the midline.
An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is:
bloody mucus drainage from vagina
When using the second Leopolds maneuver in fetal assessment, the nurse would palpate (the):
both sides of the maternal abdomen.
If a notation on the clients health record states that the fetal position is LSP, this means that the:
buttocks are in the left posterior quadrant of the pelvis.
A couple asks the nurse to explain the use of breathing techniques during the labor process. Which should the nurse include in the response? (Select all that apply.)
c. The breathing pattern chosen to use during labor should be practiced frequently. d. Focused or controlled breathing techniques are considered just one of many coping strategies. e. One helpful technique with breathing is to visualize oxygen entering on inhalation and tension leaving on exhalation.
To determine if the client is in true labor, the nurse would assess for changes in:
cervical dilation.
A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husbands hand away and shouts, Dont touch me! This behavior is most likely:
common during the transition phase of labor.
A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after birth because of:
decreased melanocyte-stimulating hormone.
The assessment finding which indicates that the client is in the active phase of the first stage of labor is:
dilation of 5 cm.
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be:
discharged home to await the onset of true labor.
When assessing the A of the acronym REEDA, the nurse should assess the:
edges of the episiotomy.
A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:
fetal heart rate, maternal vital signs, and the womans nearness to birth.
The nurse has given the newborn an Apgar score of 5. She should then:
gently stimulate by rubbing the infants back while administering O2.
A nursing priority during admission of a laboring client who has not had prenatal care is:
identifying labor risk factors.
Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have:
increased blood volume.
During labor a vaginal examination should be performed only when necessary because of the risk of:
infection.
An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates:
lightening.
If a womans fundus is soft 30 minutes after birth, the nurses first response should be to:
massage the fundus.
The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by:
pulling the cervix over the fetus and amniotic sac.
The nurse thoroughly dries the infant immediately after birth primarily to:
reduce heat loss from evaporation.
Uncontrolled maternal hyperventilation during labor results in:
respiratory alkalosis.
The primary difference between the labor of a nullipara and that of a multipara is:
total duration of labor.
A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with:
umbilical cord compression.
