Test 2 Questions

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

ANS: 1 and 3 are correct. 1. This is a sign of placental separation. 2. Once second stage is complete, the baby is no longer in utero. 3. This is a sign of placental separation. 4. Dilation and effacement are complete before second stage begins. 5. Rectal pressure is usually a sign of fetal descent. Once the second stage is complete, the baby is no longer in utero

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1,000 mL of Ringer's lactate. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.

ANS: 1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should receive an order to infuse Ringer's lactate before the woman is given regional anesthesia. 3. It is not necessary to place the woman in the Trendelenburg position. 4. The blood pressure will need to be monitored every 5 minutes for 15 minutes after administration of the anesthesia, but not before. 5. The nurse should ask the woman to empty her bladder.

The nurse is monitoring a woman, G2 P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; -3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; -3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1. Labor is progressing well. 2. The woman is likely carrying a macrosomic fetus. 3. The baby is in fetal distress. 4. The woman will be in second stage in about five hours.

ANS: 2 1. Although dilation is progressing, the station is unchanged. The baby, therefore, is not descending into the birth canal. The nurse cannot conclude that the labor is progressing well. 2. Because the presenting part is not descending into the birth canal, the nurse can logically conclude that the baby is macrosomic. 3. There is no sign of fetal distress in this scenario. 4. This woman is a multigravida. The average length of the transition phase of labor for multiparas is 10 minutes.

A woman being induced with oxytocin (Pitocin) is contracting every 3 min s30 seconds. Suddenly the woman becomes dypsneic and cyanotic, and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.

ANS: 3 1. Blood pressure assessment is important, but it is not the priority action. 2. FH assessment is important, but it is not the priority action. 3. The nurse's priority action is to administer oxygen. 4. It is appropriate to stop the infusion, but that is not the priority action.

The childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

ANS: 3 1. The alternate pant-blow technique is used during stage 1 of labor. 2. Rhythmic, shallow breaths are used during stage 1 of labor. 3. Open glottal pushing is used during stage 2 of labor. 4. Slow chest breathing is used during stage 1.

The nurse is assessing the Bishop score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.

ANS: 3, 4, and 5 are correct. 1. Gestational age is not part of the Bishop score. 2. The status of the membranes is not part of the Bishop score. 3. Cervical dilation is part of the Bishop score. 4. Fetal station is part of the Bishop score. 5. Cervical position is part of the Bishop score.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing

ANS: 4 1. It is inappropriate to encourage her to have an epidural at this time. 2. It is inappropriate to encourage her to have an IV analgesic at this time. 3. A change of position might help but will probably not be completely effective. 4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual odor." 3. "Your labor should start very soon." 4. "Have you felt the baby move since the membranes broke?"

ANS: 4 1. This comment is inappropriate. The nurse should ask the woman whether or not she has felt fetal movement. 2. The amniotic fluid smells musty but it does not naturally have an offensive smell. 3. This statement is likely true but the nurse should ask the woman whether or not she has felt fetal movement and the woman should be advised to go to the hospital for evaluation. 4. The most important information needed by the nurse should relate to the health and well-being of the fetus. Fetal movement indicates that the baby is alive.

A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.

ANS: 4 1. The woman does have a legal right not to sign the form. To badger her about her decision is inappropriate. 2. Practitioners who perform surgery on a client who has refused to sign a consent form can be arrested for assault and battery. 3. It is inappropriate to scare a patient into submission. 4. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated.

A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 3 min s 90 sec to q 2 min s 60 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.

ANS: 4 and 5 are correct. 1. A decrease in the frequency of the contractions from q 3 min s90 sec to q 2 min s60 is the expected, therapeutic response. This change does not warrant stopping the medication. 2. A change in fetal heart rate pattern from no decelerations to early decelerations is a benign change. This change does not warrant stopping the medication. 3. Minimal variability is a sign of poor fetal oxygenation, whereas moderate variability is a sign of good fetal oxygenation. This change does not warrant stopping the medication. 4. When the fetal heart rate pattern is greater than 200 bpm, the medication should be stopped. 5. Terbutaline is contraindicated when the membranes have ruptured prematurely.

A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask

ANS: 1 1. The nurse should assess the fetal heart and the maternal pulse simultaneously. 2. It is not necessary to notify the doctor at this time. 3. It is not necessary to stop the medication at this time. 4. It is not necessary to administer oxygen to the mother at this time.

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

ANS: 1 1. The nurse would expect the woman to be 2 cm dilated. 2. At 4 cm, the woman is entering the active phase of labor. 3. At 8 cm, the woman is in the transition phase of labor. 4. At 10 cm, the woman is in the second stage of labor.

A woman, 32 weeks' gestation, contracting every 3 min s 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.

ANS: 1 1. The urinary output should be carefully monitored. 2. Magnesium sulfate administration does not place clients at high risk for a temperature elevation. 3. Magnesium sulfate administration does not place clients at high risk for cessation of peripheral circulation. 4. Magnesium sulfate administration does not place clients at high risk for retinal edema.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

ANS: 1 1. The first action the nurse should take is to place the woman in the knee-chest position. 2. The nurse should assess the fetal heart rate, but this is not the first action. 3. Oxygen should be administered, but this is not the first action. 4. The physician should be advised, but this is not the first action.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min s 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

ANS: 1 1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip. 2. Oxygen should be administered, but the mask should be put on after the oxytocin has been turned off. 3. Repositioning is indicated, but should be performed after the oxytocin has been turned off. 4. The obstetrician should be called, but after the oxytocin has been turned off.

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.

ANS: 2 1. It is inappropriate to discourage a laboring client from taking pain medication simply because she has abused drugs. 2. The nurse should notify the health care practitioner of the client's request. 3. Substance abuse is not a contraindication for analgesic medication in labor. 4. Although the client may benefit from labor breathing, she has requested pain medication and that request should be acted upon

A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.

ANS: 1 1. A common side effect of Cytotec is diarrhea and labor contractions are often first felt in the back. 2. Hypothermia and rectal pain are not associated with Cytotec administration. 3. Urinary retention and rash are not associated with Cytotec administration. 4. Tinnitus and respiratory distress are not associated with Cytotec administration. TEST-TAKING TIP: Cytotec (misoprostol) is a synthetic prostaglandin medication used to ripen the cervix for induction. Gastrointestinal side effects are commonly seen when prostaglandin is used, because the gastrointestinal system is adjacent to the vagina where the medication is inserted. In addition, the nurse must be watchful for signs of labor.

A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.

ANS: 1 1. Because the client will have a cesarean section with anesthesia, the woman should be taught coughing and deepbreathing exercises for the postoperative period. 2. Because the woman will not be going through labor, it is inappropriate to teach her about the phases of the first stage of labor. 3. Because the woman will not be going through labor, it is inappropriate to teach her about Lamaze breathing techniques. 4. Because the woman will not be going through labor, it is inappropriate to teach her about Leboyer hydrobirthing.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

ANS: 1 1. Fundal heights increase during pregnancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour. 2. Pain-free vaginal bleeding is consistent with a diagnosis of placenta previa. 3. The nurse would expect to see late fetal heart decelerations. 4. This is not an infectious state. The nurse would not expect to see hyperthermia.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

ANS: 1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 3. Expelling the mucous plug is not sufficient reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconiumstained fluid. The client needs to be assessed. 5. The latent phase of labor can last up to a full day. In addition, Braxton Hicks' contractions can last for quite a while. Even though a woman may feel cramping for 4 hours or more, she may not be in true labor.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

ANS: 1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates progression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 3. The amniotic sac can rupture at any time. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The gravida's ability to work with her labor is more dependent on her level of pain and her preparation for labor than on the phases and/or stages of labor.

The nurse in the obstetrician's office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day.

ANS: 1, 2, and 5 are correct. 1. This client is high risk for PTL because she is over 35 years of age and in an abusive relationship. 2. A previous preterm delivery places a client at increased risk of preterm labor. 3. The presence of a two-vessel cord does not place a client at increased risk of preterm labor. 4. A history of long menstrual periods does not place a client at increased risk of preterm labor. 5. A woman who smokes cigarettes is at high risk for preterm labor.

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.

ANS: 1, 2, and 5 are correct. 1. When a baby is in the breech presentation, there is increased risk of prolapsed cord. 2. The presenting part is floating, which increases the risk of prolapsed cord. 3. With decreased quantity of amniotic fluid there is no increased risk of prolapsed cord. 4. 2-cm dilation is not a situation that is at high risk for prolapsed cord. 5. When a baby is in the transverse lie, there is increased risk for prolapsed cord.

A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.

ANS: 1, 4, and 5 are correct. 1. The client's hepatitis B status should be assessed. 2. The client's rubeola status is not immediately important. 3. The client's varicella status is not immediately important. 4. The client's group B streptococcus status should be assessed. 5. The client's HIV/AIDS status should be assessed.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate.

ANS: 2 1. Although this client is light-headed, her problem is unlikely related to her blood pressure. 2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. 3. It is unnecessary for this client to be moved to her side. 4. The baby is not in jeopardy at this time.

An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes s 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.

ANS: 2 1. As long as oxytocin is increased slowly and the contraction pattern and fetal response are monitored carefully, there is no absolute, unsafe maximum dosage of oxytocin. 2. The practitioner should increase the dosage of oxytocin at a minimum time interval of every 30 minutes. 3. Although postdates babies are higher risk for fetal distress, it is not contraindicated to induce with oxytocin. 4. A 60-second contraction duration is normal. TEST-TAKING TIP: The half-life (the time it takes half of a medication to be metabolized by the body) of oxytocin is relatively long— about 15 minutes. And at least 3 half-lives usually elapse before therapeutic responses are noted. Increasing the infusion rate too rapidly, therefore, can lead to hyperstimulation of the uterine muscle and consequent fetal distress.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

ANS: 2 1. Engagement is achieved when the baby's presenting part reaches an imaginary line between the ischial spines. The station of the fetal head, as described in the question, is past the inlet. 2. The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis. 3. The baby is physiologically unable to enter the true pelvis when in a horizontal lie. 4. The attitude of the baby is not discussed in the ultrasound statement.

The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick count assessments.

ANS: 2 1. Fetal fibronectin is not related to glucose metabolism. 2. Positive fetal fibronectin levels are seen in clients who deliver preterm. 3. Fetal fibronectin is not related to hypertensive conditions. 4. Fetal fibronectin is not related to fetal distress.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.

ANS: 2 1. Frequency and duration are important, but they are not the highest priority at this time. 2. Maternal temperature is the highest priority. 3. Cervical change is important, but it is not the highest priority at this time. 4. Maternal pulse rate is important, but it is not the highest priority at this time.

A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.

ANS: 2 1. Human papillomavirus is not an indication for cesarean section. 2. Standard precautions are indicated in this situation. 3. A baby born to a woman with HPV receives standard care in the well-baby nursery. 4. HPV is not airborne. A mask is not required. TEST-TAKING TIP: Although HPV is a sexually transmitted infection and it can in rare instances be contracted by the neonate from the mother, the Centers for Disease Control and Prevention do not recommend that cesarean section be performed merely to prevent vertical transmission of HPV

An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.

ANS: 2 1. Hypertension is not related to the diagnosis of placenta accreta. 2. The nurse would expect the woman to hemorrhage. 3. Bradycardia is not related to the diagnosis of placenta accreta. 4. Hyperthermia is not related to the diagnosis of placenta accreta.

A full-term client, contracting every 15 min s 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.

ANS: 2 1. Intermittent fetal heart auscultation is appropriate at this time. 2. Vaginal examination is contraindicated. 3. Intravenous fluid administration is appropriate at this time. 4. Nipple stimulation is appropriate at this time. TEST-TAKING TIP: The client in this scenario is at risk of an ascending infection from the vagina to the uterine body because she has prolonged rupture of membranes. Any time a vaginal examination is performed, the chance of infection rises. Nipple stimulation is appropriate because endogenous oxytocin will be released, which would augment the client's weak labor pattern.

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

ANS: 2 1. Intravenous oxytocin administration is inappropriate. This would cause the uterus to contract markedly but would not assist with the delivery of the fetal shoulders. 2. Flexing the woman's hips sharply toward her abdomen, called McRoberts' maneuver, is appropriate. 3. Oxygen administration will not assist with the delivery of the fetal shoulders. 4. Fundal pressure is inappropriate.

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

ANS: 2 1. The client may have a urinary tract infection with blood in the urine. First, however, the nurse should acknowledge the client's concerns. 2. The nurse is using reflection to acknowledge the client's concerns. 3. Although the woman's statement is consistent with the expulsion of the mucous plug, this response ignores the fact that the client is frightened by what she has seen. 4. The nurse will want to clarify that the woman isn't actually bleeding, but the question should follow an acknowledgment of the woman's concerns.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

ANS: 2 1. The woman should not push until the next contraction. She should be allowed to sleep at this time. 2. The woman's privacy should be maintained while she is resting. 3. The woman is in no apparent distress. Vital sign assessment is not indicated. 4. The woman is in no apparent distress. Oxygen is not indicated.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

ANS: 2 1. This comment would be consistent with a client in the latent phase of labor. 2. This comment is consistent with a woman in the transition phase of stage 1. 3. This comment could be made at a variety of times during the labor. 4. This comment is consistent with a woman in stage 2 labor.

The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 130 seconds. 4. Attitude flexed.

ANS: 2 1. Uterine hyperstimulation can be seen with moderate intensities. 2. A frequency pattern of every 3 minutes is ideal. 3. A duration of 130 seconds is indicative of tachysystole. 4. The attitude of the baby has nothing to do with hyperstimulation.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions is recommended prior to performing this assessment? 1. Place the client in the lateral recumbent position. 2. Insert an internal fetal monitor electrode. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

ANS: 2 1. When assessing the variability of the fetal heart, the mother can be in any position. 2. Before the variability can be accurately assessed, an internal fetal heart electrode should be applied. 3. Only after assessing a poor fetal monitor tracing would the nurse administer oxygen. 4. Variability is unrelated to fetal movement.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

ANS: 2 1. With pain and increased energy needs, the pulse rate often increases. 2. The blood pressure rises dramatically. 3. Although the woman is working very hard, her temperature should remain normal. 4. With pain and increased energy needs, the respiratory rate often increases.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min s 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

ANS: 2 1. Women may contract without being in true labor. 2. Once the cervix begins to dilate, a client is in true labor. 3. Membranes can rupture before true labor begins. 4. Engagement can occur before true labor begins.

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

ANS: 3 1. The maternal blood pressure is not the priority assessment after an amniotomy. 2. The maternal pulse is not the priority assessment after an amniotomy. 3. It is essential to assess the fetal heart rate immediately after an amniotomy. 4. Fetal fibronectin is assessed during pregnancy. It is not assessed once a woman enters labor.

The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal, warranting further sampling. 4. The results are within normal limits.

ANS: 3 1. The results are equivocal; therefore, the nurse cannot conclude that the baby is severely acidotic. 2. Practitioners usually will repeat the test a few minutes after an equivocal result. 3. Further testing is indicated. 4. The results are not within normal limits. TEST-TAKING TIP: Some practitioners perform fetal scalp sampling when there is a decrease in fetal heart variability. A normal fetal pH is defined as 7.25 to 7.35. An acidotic fetus has a pH that is less than 7.20. When the pH is between 7.20 to 7.25, the value is considered to be equivocal with a need for further testing. Usually interventions are instituted—oxygen applied, position changed, IV fluid increased—and another sampling is done in 10 to 15 minutes.

The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL. 2. G2 P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2 P1001, 39 weeks, Rh-negative, today's hematocrit 31%

ANS: 3 1. Although placenta previa is an obstetric complication, the hemoglobin is within normal limits. 2. Although diabetes mellitus is an obstetric complication, the blood glucose is within normal limits. 3. A placental abruption is a life-threatening situation for the fetus. It has been 15 minutes since the fetal heart was assessed. This is the nurse's priority. 4. A woman who is Rh-negative may or not may not be carrying a baby who is Rhpositive. Either way, a hematocrit of 31%, although low, is not an emergent value.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

ANS: 3 1. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed in the LUQ. 2. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed LLQ. 3. Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. 4. The monitor electrode should have been placed in the RLQ if the nurse had assessed a vertex presentation.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

ANS: 3 1. Breathing will help with contraction pain, but is not as effective when a client is experiencing back labor. 2. It is inappropriate automatically to encourage mothers to have anesthesia or analgesia in labor. There are other methods of providing pain relief. 3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head. 4. Hydrotherapy is very soothing but will not provide direct relief.

A preterm labor client, 30 weeks' gestation, who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."

ANS: 3 1. Decadron is not a tocolytic. 2. Decadron is not an anti-infective. 3. Decadron is a steroid that hastens the maturation of the fetal lung fields. 4. Decadron is not an analgesic.

On examination, it is noted that a full-term primipara in active labor is right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

ANS: 3 1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines. 2. The fetal head is well past engagement. Engagement is defined as 0 station. 3. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away. 4. External rotation does not occur until after delivery of the fetal head.

A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.

ANS: 3 1. Oxytocin is safe to administer if a client has preeclampsia. 2. The frequency is within normal limits. 3. The duration of the contractions is prolonged. The baby will be deprived of oxygen. 4. The FH is within normal limits

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min s 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

ANS: 3 1. Oxytocin will increase the client's contractions. The administration of this medication is inappropriate at this time. 2. Methergine should never be administered unless the placenta is already delivered. 3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time. 4. Morphine sulfate is an opioid. There is no rationale for its administration in the scenario.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.

ANS: 3 1. The client is hemodynamically stable. Her blood pressure needs to be assessed about every 1 hour at this time. 2. The client is hemodynamically stable. Her pulse needs to be assessed about every 4 hours at this time. 3. The client's bladder should be palpated. 4. There is nothing in the scenario that implies that the client's lung fields need to be assessed.

The health care practitioner performed an amniotomy 5 minutes ago on a client, G3 P1011, 40 weeks' gestation, -4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is post-term. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.

ANS: 3 1. The fetus is full-term. Post-term is defined by most texts as 42 weeks' gestation or later and by some as 41 weeks' gestation or later. 2. The fetus is not breech; it is vertex. 3. It is likely that the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelerations are seen on the FH monitor. 4. If the client were infected, the amniotic fluid would be foul smelling.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

ANS: 3 1. The frequency of labor contractions decreases. It does not increase. 2. Labor contractions increase in intensity. They do not become milder. 3. This response indicates that the labor contractions are increasing in intensity. 4. This client has slept through the "tightening" and there is no increase in intensity. It is unlikely that she is in true labor.

Which of the following situations in a fully dilated client is incompatible with a forceps delivery? Select all that apply. 1. Maternal history of asthma. 2. Right occiput posterior position at +4 station. 3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute at -1 station. 5. Maternal history of cerebral palsy.

ANS: 3 and 4 are correct. 1. Asthmatic clients, although needing careful monitoring, are able to deliver vaginally. 2. It would be appropriate to deliver a baby whose position and station are ROP and +4 via forceps. 3. A baby in transverse lie is physically incapable of delivering vaginally. 4. It is not appropriate to deliver a baby vaginally who is at -1 station. The baby has yet to engage. This baby would likely be delivered by cesarean section for prolonged fetal distress. 5. Clients with cerebral palsy may be delivered with forceps.

A nurse is caring for a gravid client who is G1 P0000, 35 weeks' gestation. Which of the following would warrant the nurse to notify the woman's health care practitioner that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.

ANS: 3 and 4 are correct. 1. The presence of contractions without cervical change is not diagnostic of preterm labor. 2. Preterm labor is defined as cervical effacement of greater than 80%. Although the client has effaced slightly, a diagnosis of preterm labor cannot as yet be made. 3. The dilation of 3 cm is indicative of preterm labor. 4. A cervical length of 2 cm is indicative of preterm labor. 5. The presence of 30-second-duration contractions is not diagnostic of preterm labor.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

ANS: 3, 4, and 5 are correct. 1. Hypnotic suggestion is usually not included in childbirth education based on the Lamaze method. 2. Rhythmic chanting is usually not included in childbirth education based on the Lamaze method. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education.

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 g/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30

ANS: 4 1. Oxygen saturations are noninvasive assessments whereas fetal scalp sampling assessments are performed on blood obtained from the fetal scalp. Fetal oxygen saturation levels are well below those seen in extrauterine life—approximately 50% to 75%. 2. Normal fetal hemoglobin levels are well above those seen in extrauterine life—14 to 20 g/dL. 3. This fetal glucose level is indicative of maternal hyperglycemia. 4. This fetal pH value is within normal limits.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

ANS: 4 1. This client is fully dilated and effaced, but the baby is not yet engaged. Until the baby descends and stimulates rectal pressure, it is inappropriate for the client to begin to push. 2. Fundal pressure is inappropriate. 3. Many women push in the squatting position, but it is too early to push at this time. 4. Monitoring for rectal pressure is appropriate at this time. TEST-TAKING TIP: Although the test taker may see in practice that women are encouraged to begin to push as soon as they become fully dilated, it is best practice to wait until the woman exhibits signs of rectal pressure. Pushing a baby that is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord.

A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.

ANS: 4 1. Although the blood glucose of a client with diabetes is important, it can wait. 2. Although the vaginal blood loss assessment of a client who has had a spontaneous abortion is important, it is usually minimal. This client can wait. 3. It is important to assess the patellar reflexes of a client with preeclampsia, but with mild disease, that action can wait. 4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.

ANS: 4 1. Hyperreflexia is seen with severe preeclampsia. The magnesium sulfate is being administered to depress the hyperreflexia. 2. 30 mL/hr is an acceptable urinary output. 3. A respiratory rate of 16 rpm is within normal limits. 4. A serum magnesium level of 9 g/dL is dangerously high. The health care practitioner should be notified.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

ANS: 4 1. Moderate variability is indicative of fetal health, not of hypoxia. 2. A change in variability indicates acidosis, not alkalosis. In this situation, there is no indication of acidosis. 3. During sleep cycles, fetal heart rate variability decreases. 4. Moderate variability is indicative of fetal health.

The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.

ANS: 4 1. Oxygen administered during labor should be delivered via a tight-fitting mask at 8 to 10 liters per minute. 2. The client should be positioned on her side or in Trendelenburg position. 3. The best way to monitor the fetus is with an internal electrode. 4. Increasing the IV rate helps to improve perfusion to the placenta.

A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.

ANS: 4 1. The expected outcome from the administration of Cervidil is an increase in the Bishop score. 2. A fetal heart rate of 152 is within normal limits and not significantly different from the original baseline of 156. 3. A respiratory rate of 24 is not a contraindication to the administration of prostaglandins for cervical ripening. 4. A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication. TEST-TAKING TIP: A frequency of 1 minute, even if the duration were 30 seconds, would mean that there were only 30 seconds when the uterine muscle was relaxed. This short amount of time would not provide the placenta with enough time to be sufficiently perfused. Fetal bradycardia is a likely outcome to such a short frequency period.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

ANS: 4 1. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. 2. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. 3. Although this client is fully dilated, the cervix is not fully effaced and the baby has not descended far enough. 4. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

ans: 1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 4. The fetal heart pattern should be assessed every 1 hour during the latent phase of a low-risk labor. It is not standard protocol to assess every 10 minutes. 5. The nurse should assess the fetal heart before the woman ambulates.