OB Exam 2 MC
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? a. Variability b. Accelerations c. Early decelerations d. Variable decelerations
d. Variable decelerations
When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? a. Hold your breath and push through entire contraction. b. Use chest-breathing with the contraction. c. Pant and blow during each contraction. d. Wait until you feel the urge to push.
d. Wait until you feel the urge to push.
A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action? a. Sit the client in a high Fowler's position. b. Call the pharmacy for a tocolytic medication. c. Get intravenous (IV) therapy equipment and solution from the storage area. d. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
d. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for? a. Delivery of the fetus b. Strict monitoring of intake and output c. Complete bed rest for the remainder of the pregnancy d. The need for weekly monitoring of coagulation studies until the time of delivery
a. Delivery of the fetus
After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? a. Reposition the laboring woman to knee-chest. b. Assess the vagina and cervix with a gloved hand. c. Notify the health care provider of the need for an amnioinfusion. d. Document the description of the fetal bradycardia in the nursing notes.
b. Assess the vagina and cervix with a gloved hand.
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? a. Prepare the client for an ultrasound. b. Obtain equipment for a manual pelvic examination. c. Prepare to draw a hemoglobin and hematocrit blood sample. d. Obtain equipment for external electronic fetal heart rate monitoring.
b. Obtain equipment for a manual pelvic examination.
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? a. "I should stay on the diabetic diet." b. "I should perform glucose monitoring at home." c. "I should avoid exercise because of the negative effects on insulin production." d. "I should be aware of any infections and report signs of infection immediately to my health care provider (HCP)."
c. "I should avoid exercise because of the negative effects on insulin production."
A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? a. Placenta previa b. Polyhydramnios c. Abruptio placentae d. Gestational hypertension
c. Abruptio placentae
The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? a. Fentanyl b. Morphine sulfate c. Butorphanol tartrate d. Meperidine hydrochloride
c. Butorphanol tartrate
The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? a. Checking for edema b. Monitoring daily weight c. Monitoring the apical pulse d. Monitoring the temperature
c. Monitoring the apical pulse
By the end of the second stage of labor, the nurse would expect which of the following events? The a. cervix is fully dilated and effaced b. placenta is detached and expelled c. fetus is born and on mother's chest d. woman to request pain medication
c. fetus is born and on mother's chest
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? a. "I won't be in labor until my baby drops." b. "My contractions will be felt in my abdominal area." c. "My contractions will not be as painful if I walk around." d. "My contractions will increase in duration and intensity."
d. "My contractions will increase in duration and intensity."
The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? a. Chest pain b. A rigid abdomen c. A soft and boggy uterus d. Complaints of severe abdominal pain
d. Complaints of severe abdominal pain
Women who are obese have a greater risk of developing which of the following during pregnancy? a. Type 1 diabetes b. Hypotension c. Low birth weight infant d. Gestational hypertension
d. Gestational hypertension
The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. a. Plan induction at 35 weeks. b. Plan amniocentesis at this time. c. Schedule a biophysical profile immediately. d. Plan for weekly nonstress tests at 32 weeks. e. Obtain nutritional counseling with a dietitian.
d. Plan for weekly nonstress tests at 32 weeks. e. Obtain nutritional counseling with a dietitian.
The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? a. Administer oxygen by face mask. b. Clear and maintain an open airway. c. Administer magnesium sulfate intravenously. d. Assess the blood pressure and fetal heart rate.
b. Clear and maintain an open airway.
During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? a. "Diet and insulin needs change during pregnancy." b. "I will plan my diet based on the results of urine glucose testing." c. "I will need to eat 600 more calories every day because I am pregnant." d. "I can continue with the same diet as before pregnancy, as long as it is well balanced."
a. "Diet and insulin needs change during pregnancy."
Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. a. Prepare for delivery. b. Administer a tocolytic. c. Administer an opioid antagonist. d. Turn the woman to a lateral position. e. Increase the rate of the intravenous infusion. f. Administer oxygen by face mask at 10 L/minute.
d. Turn the woman to a lateral position. e. Increase the rate of the intravenous infusion. f. Administer oxygen by face mask at 10 L/minute.
Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? a. "I feel like I need to push." b. "My contractions seem to be getting stronger." c. "I am glad that I have several minutes to rest between contractions." d. "Warm fluid is running down my legs each time I have a contraction."
a. "I feel like I need to push."
The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? a. "I will need to increase my insulin dosage during the first 3 months of pregnancy." b. "My insulin dose will likely need to be increased during the second and third trimesters." c. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." d. "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."
a. "I will need to increase my insulin dosage during the first 3 months of pregnancy."
A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? a. "My vision for the past 2 days has been really fuzzy." b. "The swelling in my hands and ankles has gone down." c. "I had heartburn yesterday after I ate some spicy foods." d. "I had a headache yesterday, but I took some acetaminophen and it went away."
a. "My vision for the past 2 days has been really fuzzy."
When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: a. 15 to 30 minutes b. 5 to 10 minutes c. 45 to 60 minutes d. 60 to 75 minutes
a. 15 to 30 minutes
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? a. Administer oxygen via face mask. b. Place the mother in a supine position. c. Increase the rate of the oxytocin intravenous infusion. d. Document the findings and continue to monitor the fetal patterns.
a. Administer oxygen via face mask.
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. a. Age 54 b. Body mass index of 28 c. Previous difficulty with fertility d. Administration of oxytocin for induction e. Potassium level of 3.6 mEq/L (3.6 mmol/L)
a. Age 54 b. Body mass index of 28 c. Previous difficulty with fertility
The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. a. Assess blood pressure. b. Check the urine for protein. c. Assess deep tendon reflexes. d. Discuss the need for hospitalization. e. Teach the importance of keeping track of a daily weight.
a. Assess blood pressure. b. Check the urine for protein. c. Assess deep tendon reflexes. e. Teach the importance of keeping track of a daily weight.
A woman is being discharged after receiving treatment for a hydatidiform molar pregnancy. The nurse should include which of the following in her discharge teaching? a. Do not become pregnant for at least a year; use contraceptives to prevent it b. Have the client's blood pressure checked weekly in the clinic c. RhoGAM must be given within the next month to her at the clinic d. An amniocentesis can detect a recurrence of this disorder in the future
a. Do not become pregnant for at least a year; use contraceptives to prevent it
Which of the following practices would not be included in a physiologic birth? a. Early induction of labor <39 weeks gestation b. Freedom of movement for the laboring woman c. Continuous presence and support throughout labor d. Encouraging spontaneous pushing when urge felt
a. Early induction of labor <39 weeks gestation
The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? a. Forceps delivery b. Schultz presentation c. Hypotonic contractions d. Weak bearing-down efforts
a. Forceps delivery
The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? a. Increased insulin b. Decreased insulin c. Increased caloric intake d. Decreased protein intake
a. Increased insulin
The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. a. Keep the room semi-dark. b. Initiate seizure precautions. c. Pad the side rails of the bed. d. Avoid environmental stimulation. e. Allow out-of-bed activity as tolerated.
a. Keep the room semi-dark. b. Initiate seizure precautions. c. Pad the side rails of the bed. d. Avoid environmental stimulation.
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? a. Monitor for fetal movement. b. Monitor the maternal blood glucose. c. Instruct the client to maintain complete bed rest. d. Instruct the client to restrict dietary sodium and any food items that contain sodium.
a. Monitor for fetal movement.
The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? a. Monitoring fetal status b. Providing comfort measures c. Changing the client's position frequently d. Keeping the significant other informed of the progress of the labor
a. Monitoring fetal status
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? a. Notify the health care provider (HCP). b. Continue monitoring the fetal heart rate. c. Encourage the client to continue pushing with each contraction. d. Instruct the client's coach to continue to encourage breathing techniques.
a. Notify the health care provider (HCP).
Interventions that are underutilized in promoting a normal birth. Select all that apply. a. Oral nutrition and fluids in labor b. Open glottis pushing in the second stage of labor c. Skin-to-skin contact after birth for infant bonding d. Routine artificial rupture of membranes (amniotomy) e. Labor induction with Pitocin given intravenously f. Routine episiotomy to shorten labor length
a. Oral nutrition and fluids in labor b. Open glottis pushing in the second stage of labor c. Skin-to-skin contact after birth for infant bonding
The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and should expect to note which prescribed treatment for this condition? a. Oxytocin infusion b. Increased hydration c. Administration of a tocolytic medication d. Administration of a medication that will provide sedation
a. Oxytocin infusion
A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed? a. Palpate the bladder at frequent intervals. b. Encourage the woman to walk to progress the labor. c. Assess the blood pressure frequently for hypertension. d. Encourage the woman to assume a supine position after the epidural has been placed.
a. Palpate the bladder at frequent intervals.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? (Select all that apply.) a. Proteinuria b. Hypertension c. Low-grade fever d. Generalized edema e. Increased pulse rate f. Increased respiratory rate
a. Proteinuria b. Hypertension
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? a. Provide pain relief measures. b. Prepare the client for an amniotomy. c. Promote ambulation every 30 minutes. d. Monitor the oxytocin infusion closely.
a. Provide pain relief measures.
The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? a. The client's fear b. The client's fatigue c. The client's inability to control the situation d. The client's inability to cope with the situation
a. The client's fear
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data should alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? Select all that apply. a. The client's last baby weighed 10 lb at birth. b. The client has a family history of type 1 diabetes. c. The client is 5 feet, 3 inches tall and weighs 165 lb. d. The client's previous deliveries were by cesarean section. e. The client has a history of gestational diabetes with her previous pregnancy.
a. The client's last baby weighed 10 lb at birth. e. The client has a history of gestational diabetes with her previous pregnancy.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? a. The client's last baby weighed 10 pounds at birth. b. The client's previous deliveries were by cesarean section. c. The client has a family history of cardiovascular disease. d. The client is 5 feet, 3 inches tall and weighs 165 pounds.
a. The client's last baby weighed 10 pounds at birth.
The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? a. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. b. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. c. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. d. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.
a. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.
The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. a. Uterine tenderness b. Acute abdominal pain c. A hard, "boardlike" abdomen d. Painless, bright red vaginal bleeding e. Increased uterine resting tone on fetal monitoring
a. Uterine tenderness b. Acute abdominal pain c. A hard, "boardlike" abdomen e. Increased uterine resting tone on fetal monitoring
The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply. a. Vaginal bleeding b. Excessive fetal activity c. Excessive nausea and vomiting d. Larger-than-normal uterus for gestational age e. Elevated levels of human chorionic gonadotropin (hCG)
a. Vaginal bleeding c. Excessive nausea and vomiting d. Larger-than-normal uterus for gestational age e. Elevated levels of human chorionic gonadotropin (hCG)
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? a. "I will watch for the evidence of the passage of tissue." b. "I will maintain strict bed rest throughout the remainder of the pregnancy." c. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." d. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."
b. "I will maintain strict bed rest throughout the remainder of the pregnancy."
A woman is suspected of having abruptio placentae. Which of the following would the nurse expect to assess as a classic symptom? a. Painless, bright-red bleeding b. "Knife-like" abdominal pain c. Excessive nausea and vomiting d. Hypertension and headache
b. "Knife-like" abdominal pain
The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. a. Soft uterus b. Abdominal pain c. Nontender uterus d. Firm uterus by palpation e. Painless vaginal bleeding
b. Abdominal pain d. Firm uterus by palpation
A laboring woman is admitted to the labor and birth suite at 6-cm dilation. She would be in which phase of the first stage of labor? a. Latent b. Active c. Transition d. Early
b. Active
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? a. Notify the health care provider. b. Discontinue the infusion of oxytocin. c. Place oxygen on at 8 to 10 L/minute via face mask. d. Contact the client's primary support person(s) if not currently present.
b. Discontinue the infusion of oxytocin.
A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? a. Hourly b. Every 15 minutes c. Every 30 minutes d. Before each contraction
b. Every 15 minutes
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? a. Hemoglobin of 11 g/dL (110 mmol/L) b. Fetal heart rate of 180 beats/minute c. Maternal pulse rate of 85 beats/minute d. White blood cell count of 12,000 mm3 (12.0 × 109/L)
b. Fetal heart rate of 180 beats/minute
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? a. Age 35 years b. History of syphilis c. History of genital herpes d. History of diabetes mellitus
b. History of syphilis
Which of the following conditions would most likely cause a pregnant woman with type 1 diabetes the greatest difficulty during her pregnancy? a. Placenta previa b. Hyperemesis gravidarum c. Abruptio placentae d. Rh incompatibility
b. Hyperemesis gravidarum
A pregnant woman, approximately 12 weeks' gestation, comes to the emergency department after calling her health care provider's office and reporting moderate vaginal bleeding. Assessment reveals cervical dilation and moderately strong abdominal cramps. She reports that she has passed some tissue with the bleeding. The nurse interprets these findings to suggest which of the following? a. Threatened abortion b. Inevitable abortion c. Incomplete abortion d. Missed abortion
b. Inevitable abortion
Which fetal lie is most conducive to a spontaneous vaginal birth? a. Transverse b. Longitudinal c. Perpendicular d. Oblique
b. Longitudinal
The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? a. Providing comfort measures b. Monitoring the fetal heart rate c. Changing the client's position frequently d. Keeping the significant other informed of the progress of the labor
b. Monitoring the fetal heart rate
The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply. a. A tender and rigid uterus b. Painless, bright red vaginal bleeding c. Location in the lower uterine segment d. Greenish discoloration of the amniotic fluid e. Vaginal bleeding accompanied by abdominal pain
b. Painless, bright red vaginal bleeding c. Location in the lower uterine segment
The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? a. Gently push the cord into the vagina. b. Place the client in Trendelenburg's position. c. Find the closest telephone and page the health care provider (HCP) stat. d. Call the delivery room to notify the staff that the client will be transported immediately.
b. Place the client in Trendelenburg's position.
As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: a. Discomfort level is greater with false labor. b. Progressive cervical changes occur in true labor. c. There is a feeling of nausea with false labor. d. There is more fetal movement with true labor.
b. Progressive cervical changes occur in true labor.
A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? a. Restrict food and fluids. b. Reduce external stimuli. c. Monitor blood glucose levels. d. Maintain the client in a supine position.
b. Reduce external stimuli.
The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? a. Maternal fatigue b. The passage of meconium c. Coordinated uterine contractions d. Progressive changes in the cervix
b. The passage of meconium
Which of the following would the nurse include when teaching a pregnant woman about the pathophysiologic mechanisms associated with gestational diabetes? a. Pregnancy fosters the development of carbohydrate cravings. b. There is progressive resistance to the effects of insulin. c. Hypoinsulinemia develops early in the first trimester. d. Glucose levels decrease to accommodate fetal growth.
b. There is progressive resistance to the effects of insulin.
The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. a. Use of diaphragm b. Use of fertility medications c. History of Chlamydia d. Use of an intrauterine device e. History of pelvic inflammatory disease (PID)
b. Use of fertility medications c. History of Chlamydia d. Use of an intrauterine device e. History of pelvic inflammatory disease (PID)
During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? a. Moderate amount of dark red lochia drainage on peripad b. Uterine fundus palpated to the right of the umbilicus c. An oral temperature reading of 100.6° F d. Perineal area bruised and edematous beneath her ice pack
b. Uterine fundus palpated to the right of the umbilicus
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? a. Soft abdomen b. Uterine tenderness c. Absence of abdominal pain d. Painless, bright red vaginal bleeding
b. Uterine tenderness
The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client? a. "Your OGTT results indicate that your baby is at high risk for macrosomia and special considerations may be necessary at delivery." b. "Your OGTT results are within normal limits, but continuing your prenatal visits remains essential to monitor fetal growth and development." c. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." d. "Your OGTT results indicate that you are positive for gestational diabetes. You will be scheduled for a dietitian consultation to plan your daily dietary intake."
c. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated."
A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? a. A private room across from the elevator b. A semiprivate room across from the nurses' station c. A private room 2 doors away from the nurses' station d. A semiprivate room with another client who enjoys watching television
c. A private room 2 doors away from the nurses' station
Which assessment would indicate that a woman is in true labor? a. Membranes are ruptured and fluid is clear. b. Presenting part is engaged and not floating. c. Cervix is 4 cm dilated, 90% effaced. d. Contractions last 30 seconds, every 5 to 10 minutes.
c. Cervix is 4 cm dilated, 90% effaced.
The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? a. Reposition the client on the left side. b. Begin 100% oxygen via face mask. c. Document this as indicating a normal pattern. d. Call the health care provider immediately.
c. Document this as indicating a normal pattern.
Which assessment following an amniotomy should be conducted first? a. Cervical dilation b. Bladder distention c. Fetal heart rate pattern d. Maternal blood pressure
c. Fetal heart rate pattern
A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. a. Less pressure on her cervix b. Decreased number of contractions c. Increased efficiency of contractions d. The need for increased maternal blood pressure monitoring e. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
c. Increased efficiency of contractions e. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
Physiologic preparation for labor would be demonstrated by: a. Decrease in Braxton Hicks contractions felt by mother b. Weight gain and an increase in appetite by mother c. Lightening, whereby the fetus drops into true pelvis d. Fetal heart rate accelerations and increased movements
c. Lightening, whereby the fetus drops into true pelvis
The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? a. Noting whether the heart rate is greater than 140 beats/minute b. Placing the diaphragm of the Doppler on the mother's abdomen c. Palpating the maternal radial pulse while listening to the FHR d. Performing Leopold's maneuvers first to determine the location of the fetal heart
c. Palpating the maternal radial pulse while listening to the FHR
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? a. Monitor fetal heart rate continuously. b. Monitor maternal vital signs frequently. c. Perform a vaginal examination every shift. d. Administer an antibiotic per HCP prescription and per agency protocol.
c. Perform a vaginal examination every shift.
When administering magnesium sulfate to a client with preeclampsia, the nurse explains to her that this drug is given to: a. Reduce blood pressure b. Increase the progress of labor c. Prevent seizures d. Lower blood glucose levels
c. Prevent seizures
When managing a client's pain during labor, nurses should: a. Make sure the agents given do not prolong labor b. Know that all pain relief measures are similar c. Support the client's decisions and requests d. Not recommend nonpharmacologic methods
c. Support the client's decisions and requests
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. a. Early labor b. Amniotomy c. Tachycardia d. Fetal hypoxia e. Metabolic acidemia f. Congenital anomalies
c. Tachycardia d. Fetal hypoxia e. Metabolic acidemia f. Congenital anomalies
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. a. The contractions are regular. b. The membranes have ruptured. c. The cervix is dilated completely. d. The client begins to expel clear vaginal fluid. e. The spontaneous urge to push is initiated from perineal pressure.
c. The cervix is dilated completely. e. The spontaneous urge to push is initiated from perineal pressure.
The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? a. The client is 28 years of age. b. This is the second pregnancy. c. The client has a history of hypertension. d. The client performs moderate exercise on a regular daily schedule.
c. The client has a history of hypertension.
The shortest but most intense phase of labor is the: a. Latent phase b. Active phase c. Transition phase d. Placental expulsion phase
c. Transition phase
Which of the following observations would suggest that placental separation is occurring? a. Uterus stops contracting altogether. b. Umbilical cord pulsations stop. c. Uterine shape changes to globular. d. Maternal blood pressure drops.
c. Uterine shape changes to globular.
A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider (HCP). The nurse should tell the woman to call the HCP if which occurs? a. Urine test is negative for protein. b. Fetal movements are more than 4 per hour. c. Weight increases by more than 1 pound in a week. d. The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.
c. Weight increases by more than 1 pound in a week.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. a. Uterine rigidity b. Uterine tenderness c. Severe abdominal pain d. Bright red vaginal bleeding e. Soft, relaxed, nontender uterus f. Fundal height may be greater than expected for gestational age
d. Bright red vaginal bleeding e. Soft, relaxed, nontender uterus f. Fundal height may be greater than expected for gestational age
The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? a. Tongue blade b. Percussion hammer c. Potassium chloride injection d. Calcium gluconate injection
d. Calcium gluconate injection
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? a. Enlargement of the breasts b. Complaints of feeling hot when the room is cool c. Periods of fetal movement followed by quiet periods d. Evidence of bleeding, such as in the gums, petechiae, and purpura
d. Evidence of bleeding, such as in the gums, petechiae, and purpura
The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? a. Assessing the mother's reflexes b. Taking the mother's temperature c. Taking the mother's apical pulse d. Monitoring the mother's blood pressure
d. Monitoring the mother's blood pressure
Which is the priority nursing action for the client with an ectopic pregnancy? a. Assessing urine for proteinuria b. Checking the electrolyte values c. Monitoring for signs of infection d. Monitoring the pulse and blood pressure
d. Monitoring the pulse and blood pressure
A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? a. Back pain b. Abdominal pain c. Painful vaginal bleeding d. Painless vaginal bleeding
d. Painless vaginal bleeding
An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? a. Light green, with no odor b. Clear and dark amber in color c. Thick and white, with no odor d. Pale straw in color, with flecks of vernix
d. Pale straw in color, with flecks of vernix
A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? a. Urinary output of 20 mL b. Deep tendon reflexes of 2+ c. Fetal heart rate of 120 beats/minute d. Respiratory rate of 10 breaths/minute
d. Respiratory rate of 10 breaths/minute
The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? a. Urinary output has increased. b. Dependent edema has resolved. c. Blood pressure reading is at the prenatal baseline. d. The client complains of a headache and blurred vision.
d. The client complains of a headache and blurred vision.