OB Exam 3 Practice Questions from Saunders NCLEX Review
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume
Answer: 1 Rationale: The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on the left side. 4. Push on the uterus to assist in expressing clots.
Answer: 2 Rationale: If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
The nurse is monitoring a postpartum client, who delivered 1 hour ago and received epidural anesthesia for delivery, for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation
Answer: 1 Rationale: Because the client has had epidural anesthesia and is anesthetized, the client cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.
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? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin infusion closely.
Answer: 1 Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.
The nurse is assessing a pregnant client with type 1 diabetes mellitus about an understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will probably need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs will return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."
Answer: 1 Rationale: Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of the diabetes during pregnancy.
The nurse is providing postpartum instructions to a client who will be breast-feeding/chest-feeding the newborn. The nurse determines that the client has understood the instructions if the client makes which statements? Select all that apply. 1. "I need to wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "I will start my estrogen birth control pills again as soon as I get home." 4. "I know if my breasts/chest get engorged, I will limit my breast-feeding/chest-feeding and supplement the baby." 5. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
Answer: 1, 2, 5 Rationale: The postpartum client needs to wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the birthing parent or others in the home; and use of alcohol or medications. Breast-feeding/chest-feeding clients need to increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding/chest-feeding but should breast-feed/chest-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding/chest-feeding parents.
The clinic nurse is performing a psychosocial assessment of a client who is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1. The client has a history of intravenous drug use. 2. The client has a significant other who is heterosexual. 3. The client has a history of sexually transmitted infections. 4. The client has had one sexual partner for the past 10 years. 5. The client has a previous history of gestational diabetes mellitus.
Answer: 1, 3 Rationale: HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected birthing parent to the fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation
Answer: 2 Rationale: In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.
A pregnant client reports to a health care clinic, complaining of loss of appetite, cough, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction would the nurse include in the client's teaching plan? 1. Therapeutic abortion is required. 2. Isoniazid plus rifampin will be required for 9 months. 3. The client will have to stay at home until treatment is completed. 4. Medication will not be started until after delivery of the fetus.
Answer: 2 Rationale: More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Notify the obstetrician (OB). 3. Reassess the client in 2 hours. 4. Encourage increased oral intake of fluids.
Answer: 2 Rationale: Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the OB. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.
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 primary health care provider's prescriptions and would question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.
Answer: 2 Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, which is at risk for severe hypoxia.
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4. The client is a 20-year-old primigravida of average weight and height.
Answer: 2 Rationale: Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetrical problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs would the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventive measure may be prescribed. 2. Administration of subcutaneous heparin post-delivery as prescribed. 3. An overbed lift may be necessary if the client requires a cesarean section. 4. Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5. Thromboembolism stockings or sequential compression devices may be prescribed.
Answer: 2, 3, 5 Rationale: The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from an operating table to bed if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia
Answer: 3 Rationale: The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do the other three clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present a risk for hemorrhage.
The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I need to increase my sodium intake during pregnancy." 2. "I need to lower my blood volume by limiting my fluids." 3. "I need to maintain a low-calorie diet to prevent any weight gain." 4. "I need to drink adequate fluids and increase my intake of high-fiber foods."
Answer: 4 Rationale: Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver needs to be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium needs to be restricted as prescribed by the primary health care provider, because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.
The nurse evaluates the ability of a hepatitis B-positive birthing parent to provide safe bottle-feeding to the newborn during postpartum hospitalization. Which action best exemplifies the birthing parent's knowledge of potential disease transmission to the newborn? 1. The birthing parent requests that the window be closed before feeding. 2. The birthing parent holds the newborn properly during feeding and burping. 3. The birthing parent tests the temperature of the formula before initiating feeding. 4. The birthing parent washes and dries the hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
Answer: 4 Rationale: Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce complications in the birthing parent. The correct option provides the best evaluation of client understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. What action would the nurse take initially? 1. Document the finding. 2. Encourage the client to ambulate. 3. Encourage the client to increase fluid intake. 4. Contact the obstetrician (OB) to report this finding.
Answer: 4 Rationale: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse would contact the OB in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized.
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding/chest-feeding the newborn. Which client statement would indicate a need for further instruction? 1. "I need to breast-feed/chest-feed every 2 to 3 hours." 2. "I need to change the breast/chest pads frequently." 3. "I need to wash my hands well before breast-feeding/chest-feeding." 4. "I need to wash my nipples daily with soap and water."
Answer: 4 Rationale: Mastitis is inflammation of the breast/chest as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts/chest. Soap is drying and could lead to cracking of the nipples, and the client needs to be instructed to avoid using soap on the nipples. The client is taught about the importance of handwashing and the need to breast/chest-feed every 2 to 3 hours.
The nurse in a birthing room is monitoring a client with dystocia for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate
Answer: 4 Rationale: Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings would the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age
Answer: 4, 5, 6 Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation, as the blood penetrates the myometrium and causes uterine irritability.
The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1. Hypertension 2. Low-grade fever 3. Generalized edema 4. Increased pulse rate
Answer: 1 Rationale: A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions.
The nurse is teaching a postpartum client about breast-feeding/chest-feeding. Which instruction would the nurse plan to include in the teaching session? 1. The diet needs to include additional fluids. 2. Prenatal vitamins need to be discontinued. 3. Soap needs to be used to cleanse the breasts/chest. 4. Birth control measures are unnecessary while breast-feeding/chest-feeding.
Answer: 1 Rationale: The diet for a breast-feeding/chest-feeding client needs to include additional fluids. Prenatal vitamins need to be taken as prescribed, and soap would not be used on the breasts/chest because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding/chest-feeding is not a method of contraception, so birth control measures should be resumed.
A postpartum client is diagnosed with cystitis. The nurse would plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels
Answer: 2 Rationale: Cystitis is an infection of the bladder. The client need to consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Continue the oxytocin drip if infusing. 3. Place the client in a high Fowler's position. 4. Administer oxygen, 8 to 10 L/minute, via face mask.
Answer: 4 Rationale: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect, because the intravenous infusion needs to be increased (per primary health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect, because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with the legs raised to increase maternal blood volume and improve fetal perfusion.
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura
Answer: 4 Rationale: Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and needs to be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats per minute 3. The client with colostrum discharge from both breasts/chest 4. The client with lochia that is red and has a foul-smelling odor
Answer: 4 Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify my obstetrician if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."
Answer: 1 Rationale: A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises would not start immediately after abdominal surgery; the client needs to wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care of the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response would the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast/chest-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast/chest-feed for 9 months and then will need to switch to bottle-feeding."
Answer: 1 Rationale: Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the birthing parent is breast/chest-feeding. Clients who have HIV will most likely be advised not to breast/chest-feed; however, the PHCP's recommendations regarding breast/chest-feeding are always followed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.
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 would the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding
Answer: 2 Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.
A client in the first trimester of pregnancy arrives at a health care clinic and reports 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? 1. "I will watch to see if I pass any tissue." 2. "I will maintain strict bed rest throughout the remainder of the pregnancy." 3. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4. "I will avoid sexual intercourse until the bleeding has stopped and for 2 weeks following the last episode of bleeding."
Answer: 2 Rationale: Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client needs to watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider.
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the primary health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.
Answer: 2 Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client would be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse would push the call light to summon help, and other staff members would call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt is made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner would place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation.
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? 1. "I need to stay on the diabetic diet." 2. "I need to perform glucose monitoring at home." 3. "I need to avoid exercise because of the negative effects on insulin production." 4. "I need to be aware of any infections and report signs of infection immediately to my obstetrician."
Answer: 3 Rationale: Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse would include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area.
Answer: 4 Rationale: A hematoma is a localized collection of blood in the tissues of the reproductive tissues after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent.
On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse would take which initial action? 1. Document the findings. 2. Elevate the client's legs. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.
Answer: 3 Rationale: If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which would be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.
Answer: 4 Rationale: If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse would prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery
Answer: 1 Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.
The postpartum nurse is providing instructions to a client after the birth of a healthy newborn. Which time frame would the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum
Answer: 1 Rationale: After birth, the nurse would auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.
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 which risk factors in the client's history places the client at risk for this complication? Select all that apply. 1.Age 45 years 2.Body mass index of 28 3.Previous difficulty with fertility 4.Administration of oxytocin for induction 5.Potassium level of 3.6 mEq/L (3.6 mmol/L)
Answer: 1, 2, 3 Rationale: Risk factors that increase a woman's risk for dystocia include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 45 years is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with fertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal, and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions would be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Take the prescribed antibiotics until the soreness subsides. 5. Continue to breast-feed/chest-feed if the breasts/chest are not too sore. 6. Avoid decompression of the breasts/chest by breast/chest-feeding or breast/chest pump.
Answer: 1, 2, 3, 5 Rationale: Mastitis is an inflammation of the lactating breast/chest as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast/chest by breast/chest-feeding or breast/chest pump is important to empty the breast/chest and prevent the formation of an abscess.
The nurse in a maternity unit is reviewing the clients' records. Which clients would the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1.A primigravida with abruptio placentae 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 4.A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension
Answer: 1, 3, 5 Rationale: In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F (38° C) 2. An increase in the pulse rate from 88 to 102 beats per minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths per minute
Answer: 2 Rationale: During the fourth stage of labor, the birth parent blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.
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? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor
Answer: 2 Rationale: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.
The nurse is reviewing the primary health care provider's (PHCP'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 would the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer an antibiotic per prescription and per agency protocol.
Answer: 3 Rationale: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm but that bleeding is excessive. Which would be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the obstetrician (OB). 4. Place the client in Trendelenburg's position.
Answer: 3 Rationale: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position needs to be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the OB.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of dizziness. Which nursing action is most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.
Answer: 3 Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse would advise the client to get help the first few times getting out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a prescription. Option 4 is unnecessary.
The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses
Answer: 3 Rationale: Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses are a normal finding.
The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision.
Answer: 4 Rationale: If the client complains of a headache and blurred vision, the PHCP needs to be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F (37.8°C). What is the priority nursing action? 1. Document the findings. 2. Notify the obstetrician. 3. Retake the temperature in 15 minutes. 4. Increase hydration by encouraging oral fluids.
Answer: 4 Rationale: The client's temperature would be taken every 4 hours while awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the obstetrician is not necessary.
