UDC II: OB Ad.Q
Which common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? A. Intrusion on movement B. Inability to take sedatives C. Interference with breathing techniques D. Increased frequency of vaginal examinations
Answer: A Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.
At which point during a human pregnancy does the embryo become a fetus? A. During the 8th week of the pregnancy B. At the end of the 2nd week of pregnancy C. When the fertilized egg becomes implanted D. When the products of conception are seen on the ultrasound
Answer: A During the 8th week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the 2nd week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.
Which information would the nurse include in the discharge teaching of a postpartum client? A. The prenatal Kegel tightening exercises should be continued. B. A bowel movement may not occur for up to a week after the birth. C. The episiotomy sutures will be removed at the first postpartum visit D. A postpartum checkup should be scheduled as soon as menses returns
Answer: A Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.
Which recommendation would the nurse make to a pregnant client who sits almost continuously during her working hours? A. "Try to walk around every few hours during the workday." B. "Ask for time in the morning and afternoon to elevate your legs." C. "Tell your boss that you won't be able to work beyond the second trimester." D. "Ask for time in the morning and afternoon so you can go get something to eat."
Answer: A Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly those in the popliteal spaces, and may diminish venous return. Walking causes the leg muscles to contract and applies gentle pressure to the veins, thereby promoting venous return. Walking around several times each morning and afternoon will improve circulation; the legs may be elevated while the client is sitting at her desk. If the client is feeling well, there are no contraindications to working throughout her pregnancy. Adequate nourishment can be obtained during mealtimes; the client does not require extra nutrition breaks.
The nurse is teaching participants in a prenatal class regarding breast-feeding versus formula feeding. A client asks, "What is the primary advantage of breast-feeding?" Which response is most appropriate? A. "Breast-fed infants have fewer infections." B. "Breast-feeding inhibits ovulation in the mother." C. "Breast-fed infants adhere more easily to a feeding schedule." D. "Breast-feeding provides more protein than cow's milk formula does."
Answer: A Maternal antibodies are transferred from the mother in breast milk, providing protection for a longer time than do antibodies transferred to the fetus by way of the placenta. The neonate is protected by the antibodies and thus has fewer infections. The fetus' own antibody system is immature at birth. Women who breast-feed completely (day and night with no supplementary feedings) may avoid ovulation and resumption of the menstrual cycle. Use of formula or solid foods decreases breast-feeding frequency and can lead to ovulation. Ovulation generally occurs before menses, making it difficult to know when the menstrual cycle is resuming. Therefore, breast-feeding is considered one of the least reliable methods of contraception for the new mother. Because of the higher carbohydrate content of breast milk, which is digested rapidly, breast-fed infants wake more frequently than formula-fed infants. Their feeding demands take more time to regulate than do the formula-fed infants'. Breast milk has 1.1 g protein/100 mL; cow's milk has 3.5 g/100 mL. Whole cow's milk is unsuitable for infants.
For which reason is an ultrasound done during the first trimester? A. Estimate fetal age B. Detect hydrocephalus C. Rule out congenital defects D. Approximate fetal linear growth
Answer: A Measurement of the crown-rump length is useful in approximating fetal age in the first trimester. Hydrocephalus cannot be detected during the first trimester. Ultrasonography is used to detect structural defects in the second trimester. It is too early in this pregnancy to determine fetal linear growth.
Which suggestion would the nurse make to a client with morning sickness? A. "Eat dry crackers before you get out of bed." B. "Increase your fat intake before bedtime." C. "Drink high-carbohydrate fluids with meals." D. "Eat 2 small meals a day and a snack at noon."
Answer: A Nausea and vomiting in the morning occur in almost 50% of all pregnancies. Eating dry crackers before getting out of bed in the morning is a simple remedy that may provide relief. Increasing fat intake does not relieve the nausea. Drinking high-carbohydrate fluids with meals is not helpful; separating fluids from solids at mealtime is more advisable. Eating 2 small meals a day and a snack at noon does not meet the nutritional needs of a pregnant woman, nor will it relieve nausea. Some women find that eating 5 or 6 small meals daily instead of three large ones is helpful.
Which factor distinguishes true labor from false labor? A. Cervical dilation is evident. B. Contractions stop when the client walks around. C. The client's contractions progress only when she is in a side-lying position. D. Contractions occur immediately after the membranes rupture.
Answer: A Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions will increase with activity. Contractions of true labor persist in any position. Contractions may not begin until 24 to 48 hours after the membranes rupture.
Which complication is prevented by coaching a client in the second stage of labor to take a breath at least every 6 seconds while pushing with each contraction? A. Fetal hypoxia B. Perineal lacerations C. Carpopedal spasms D. Maternal hypertension
Answer: A Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.
Which is a consequence on the neonate of maternal smoking during pregnancy? A. Low birth weight B. Facial abnormalities C. Chronic lung problems D. Hyperglycemic reactions
Answer: A Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in an SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.
Where is the presenting part of the fetus when station is -1? A. 1 cm above the ischial spines B. 1 cm below the ischial spines C. Visible at the vaginal opening D. At the level of the ischial spines
Answer: A Station -1 signifies that the fetal head is 1 cm above the ischial spines and has not reached the vaginal canal. When the fetal head is 1 cm below the ischial spines, it is at station +1. When the fetal head is visible at the vaginal opening, it is at station +4. When the fetal head is level with the ischial spines, it is at station 0.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During an NST, the client asks what it means when the fetal heart rate goes up every time the fetus moves. Which is an appropriate response? A. "These accelerations are a sign of fetal well-being." B. "These accelerations indicate fetal head compression." C. "Umbilical cord compression is causing these accelerations." D. "uteroplacental insufficiency is causing these accelerations.
Answer: A The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.
During a nonstress test, the baseline fetal heart rate of 130 to 140 beats per minute rises to 160 twice and 157 once during a 20-minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take? A. Discontinue the test because the pattern is within the normal range. B. Encourage the client to drink more fluids to decrease fetal heart rate. C. Notify the primary health care provider and prepare for an emergency birth. D. Record this nonreassuring pattern and continue the test for further evaluation.
Answer: A The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. Which stage of labor would the nurse record? A. First B. Second C. Prodromal D. Transitional
Answer: A The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.
On a routine prenatal visit, which is the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time? A. Quickening B. Palpitations C. Pedal edema D. Vaginal spotting
Answer: A The recognition of fetal movement or quickening commonly occurs in primigravidas at 18 to 20 weeks' gestation; it is felt about 2 weeks earlier in multigravidas. Palpitations should not occur in the healthy primigravidas. Pedal edema may occur at the end of the pregnancy as the gravid uterus presses on the femoral arteries, impeding circulation. Immediate follow-up care is required when it occurs this early in the pregnancy. Vaginal spotting is abnormal and requires immediate follow-up care.
While caring for a client during labor, which would the nurse remember about the second stage of labor? A. It ends at the time of birth. B. It ends as the placenta is expelled. C. It begins with the transition phase of labor. D. It begins with the onset of strong contractions.
Answer: A The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.
The nurse determines that a client's placenta has separated during the third stage of labor. Which clinical finding supports the nurse's conclusion? A. A gush of blood B. Bogginess of the uterus C. Shrinkage of the uterus D. An abrupt drop in blood pressure
Answer: A There is a gush of blood when the placenta separates from the uterine wall, before the physiological clamping of the vessels at the placental site occurs. The uterus contracts and becomes firm, not boggy, when the placenta separates because of the influence of endogenous oxytocin. The uterus appears to increase, not decrease, in size when the placenta separates. The uterus changes from round to an egg shape as the placenta moves into the lower uterine segment. The blood pressure returns to prenatal status shortly after birth; the decrease is gradual and unrelated to placental separation.
Which risk to the fetus is associated with a maternal diagnosis of chorioamnionitis? Select all that apply. One, some, or all responses may be correct. A. Sepsis B. Bacteremia C. Pneumonia D. Cerebral palsy (CP) E. Respiratory distress syndrome (RDS)
Answer: A, B, C, D,& E If a pregnant client is diagnosed with chorioamnionitis, risks to the fetus include sepsis, bacteremia, pneumonia, CP, and RDS.
Which statements regarding the involution process are correct? Select all that apply. One, some, or all responses may be correct. A. Involution begins immediately after expulsion of the placenta. B. Involution is the self-destruction of excess hypertrophied tissue. C. Involution progresses rapidly during the next few days after birth. D. Involution is the return of the uterus to a nonpregnant state after birth. E. Involution may be caused by retained placental fragments and infections.
Answer: A, C, & D The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.
Which is the nurse's priority assessment for a client in the fourth stage of labor? A. Degree of relaxation B. Distention of the bladder C. Extent of breast engorgement D. Presence of mother-infant bonding
Answer: B A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility.
A client who is at 20 weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8°F (37.1°C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (prepregnancy weight was 132 lb [59.9 kg]), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). Which would the nurse do after making these assessments? A. Report the findings because the client needs immediate intervention. B. Document the results because they are expected at 20 weeks' gestation. C. Record the findings in the medical record because they are not within the norm but are not critical. D. Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.
Answer: B All data presented are expected for a client at 20 weeks' gestation and should be documented. There is no need for immediate intervention or an emergency admission because all findings are expected.
A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). Which interpretation pertains to this result? A. Immediate birth is indicated. B. This is the desired response at this stage of gestation. C. Further testing is unnecessary with this desired outcome. D. The result is inconclusive, indicating the need for further evaluation.
Answer: B An NST indicates that the fetus is healthy because there is an active pattern of fetal heart rate acceleration with movement. The result is positive and desired; immediate birth is not required. Further testing is needed. If the pregnancy continues, another test of fetal well-being will probably be done. The results were positive, not inconclusive.
Which clinical finding is an indicator of placental separation? A. Relaxation of the uterine fundus B. Lengthening of the umbilical cord C. Onset of stabbing abdominal pain D. Continuous vaginal seepage of blood
Answer: B As the placenta separates and descends down the uterus, the cord descends down the vaginal canal and appears to lengthen. The fundus contracts and becomes rounded and firmer. The client may feel a contraction; however, it is not as uncomfortable as the painful contractions at the end of the first stage of labor and is not stabbing pain. Continuous seepage of blood occurs in the presence of hemorrhage; a sudden large gush of blood heralds placental separation.
Morning sickness generally disappears by the end of which month? A. Fifth month B. Third month C. Fourth month D. Second month
Answer: B Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin but has usually diminished by the fifth month.
Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation? A. Clear, dark amber colored, and containing shreds of mucus B. Straw colored, clear, and containing shreds of mucous C. Milky, greenish yellow, and containing shreds of mucus D. Greenish yellow, cloudy, and containing little white specks
Answer: B By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.
A pregnant client asks how smoking will affect her baby. Which information about cigarette smoking will influence the nurse's response? A. It relieves maternal tension, and the fetus responds accordingly to the reduction in stress. B. The resulting vasoconstriction affects both fetal and maternal blood vessels. C. Substances contained in smoke permeate through the placenta and compromise the fetus's well-being. D. Effects are limited because fetal circulation and maternal circulation are separated by the placental barrier.
Answer: B Cigarette smoking or continued exposure to secondary smoke causes both maternal and fetal vasoconstriction, resulting in fetal growth retardation and increased fetal and infant mortality. There is no clinical evidence that smoking relieves tension or that the fetus is more relaxed. Smoking causes vasoconstriction; permeability of the placenta to smoke is irrelevant. Although the fetal and maternal circulations are separate, vasoconstriction occurs in both mother and fetus.
Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? A. Massage B. Effleurage C. Acupressure D. Counterpressure
Answer: B Effleurage is the gentle stroking of the abdomen in rhythm with her breathing during a contraction. Massage is the application of therapeutic touch and pressure on the body. Acupressure is the application of pressure along special acupressure points. Counterpressure is the application of pressure to the sacrum during a contraction.
The first day of a client's last menstrual period was July 22. Which is the estimated date of birth (EDB)? A. May 7 B. April 29 C. April 22 D. March 6
Answer: B Her EDB is April 29. Naegele's rule is an indirect, noninvasive method for estimating the date of birth: EDB = last menstrual period + 1 year - 3 months + 7 days. May 7 is beyond the EDB. April 22 and March 6 are both before the EDB.
When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." Which action would the nurse take to confirm that the membranes have ruptured? A. Take the client's oral temperature. B. Test the leaking fluid with nitrazine paper. C. Obtain a clean-catch urine specimen. D. Inspect the perineum for leaking fluid.
Answer: B Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the initial assessment. Although this may be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic fluid. Inspecting the perineum for leaking fluid will not confirm rupture of the membranes
Which response would the nurse give to a postpartum client who asks if she can drink a small glass of wine before breast-feeding the first time to help her relax? A. "I think drinking 1 glass of wine won't be a problem. Go ahead." B. "You seem a little tense. Tell me how you feel about breast-feeding." C. "You seem to find it relaxing, but you should try to find another way to relax." D. "I think drinking 1 glass of wine is alright, but you had better check with your health care provider first."
Answer: B Stating that the client seems tense and initiating a discussion honors the client's feelings and encourages expression of them; there is no reference to alcohol consumption and its relaxing effects. Alcohol ingestion should not be encouraged, because it enters the breast milk. Stating that the client needs to find another way to relax reflects the client's statement but not her underlying feelings. Suggesting that she find another way to relax may make the client defensive and shut off communication. Although alcohol ingestion should not be encouraged because it enters breast milk, the primary health care provider need not be involved because health education is within the role of the nurse.
Which statement indicates that a pregnant client requires further teaching about fetal growth and development? A. "The fetus keeps growing throughout pregnancy." B. "The fetus gets nutrients from the amniotic fluid." C. "The fetus may be underweight if it's exposed to smoke." D. "The fetus gets oxygen from blood coming through the placenta."
Answer: B The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.
Which statement made by a pregnant client after a prenatal class on fetal growth and development indicates the need for additional teaching? A. "The baby is smaller if the mother smokes." B. "The baby gets food from the amniotic fluid." C. "The baby's oxygen is provided by the mother." D. "The baby's umbilical cord has 2 arteries and 1 vein."
Answer: B The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, to supply blood containing nutrients and oxygen. "The baby is smaller if the mother smokes," "The baby's oxygen is provided by the mother," and "The baby's umbilical cord has 2 arteries and 1 vein" are all true statements, and further teaching would not be required.
The nurse admits a client with preeclampsia to the high-risk prenatal unit. Which is the next nursing action after the vital signs have been obtained? A. Calling the primary health care provider B. Checking the client's reflexes C. Determining the client's blood type D. Establishing an intravenous (IV) line
Answer: B The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary health care provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary health care provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment.
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. Which action would the nurse take after obtaining the fetal heart rate and maternal vital signs? A. Teach the client how to push with each contraction. B. Provide the client with comfort measures for relaxation. C. Prepare to have the client's blood typed and cross-matched. D. Encourage the client to perform patterned, paced breathing.
Answer: B The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor.
A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How would the nurse respond? A. "Your lower rib cage is more restricted." B. "Your diaphragm has been displaced upward." C. "Your lungs have increased in size since you got pregnant." D. "The height of your rib cage has increased since you got pregnant."
Answer: B The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration. The lower rib cage expands; it does not become restricted. There is no change in the size of the lungs during pregnancy. The thoracic cage enlarges; it does not rise.
How would the nurse explain physiological anemia to a pregnant client? A. Erythropoiesis decreases. B. Plasma volume increases. C. Utilization of iron decreases. D. Detoxification by the liver increases.
Answer: B There is a 30% to 50% increase in maternal plasma volume at the end of the first trimester, leading to hemodilution and a decrease in the concentrations of hemoglobin and erythrocytes. Erythropoiesis increases after the first trimester. Iron utilization is unrelated to the development of physiological anemia of pregnancy. Detoxification demands are unchanged during pregnancy.
According to Naegele rule, which is the expected date of delivery (EDD) of a client whose last menstrual period began on April 15? A. January 8 B. January 22 C. February 8 D. February 22
Answer: B To determine EDD with the use of Naegele rule, subtract 3 months from the date of the last menstrual period and add 7 days; in this case the EDD is January 22. January 8 is 2 weeks too early according to this formula. February 8 is too late. February 22 would be 1 month past the true EDD.
When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. Which conclusion is supported by this finding? A. There is a slow rate of involution. B. There are retained placental fragments. C. The bladder has become distended. D. The uterine ligaments are overstretched.
Answer: C A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.
Which information about adolescent growth and development would the nurse need to understand before discussing changes in body size to a 16-year-old adolescent at 24 weeks' gestation? A. Adolescents generally regain their figures 2 weeks after the birth, so size is of moderate concern. B. Adolescents are in a high-risk category, so weight gain should be limited to prevent complications. C. Body image is very important to adolescents; therefore, pregnant teenagers are overly concerned about body size. D. Physiological growth in adolescents is more rapid than in adults, so the gravid size is larger than that of an adult woman.
Answer: C Because of the changes in body size, the pregnant adolescent may feel insecure as she struggles to establish her identity. There are no data to support the statement that adolescents generally regain their figures 2 weeks after the birth. The optimal weight gain for an adolescent is at the upper range for her body mass index; this will help prevent complications, so limiting weight gain does not prevent complications. Although physiological growth is rapid, the adolescent's gravid size falls within the expected parameters for pregnant women and is not larger than that of adult women.
Which action provides support for the fetal head as it is being delivered? A. Applying suprapubic pressure B. Placing a hand firmly against the perineum C. Distributing the fingers evenly around the head D. Maintaining pressure against the anterior fontanel
Answer: C Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.
Which laboratory test is conducted during the initial prenatal visit? Select all that apply. One, some, or all responses may be correct. A. 1-hour glucose tolerance test B. 3-hour glucose tolerance test C. Cervical culture for Neisseria gonorrhoeae D. Chest x-ray for a positive tuberculosis skin test (TST) E. Group beta streptococcus (GBS) vaginal and anal cultures
Answer: C During the initial prenatal visit, a cervical culture for N. gonorrhoeae is obtained. A 1-hour glucose tolerance test is completed at 24 to 28 weeks of gestation. A 3-hour glucose tolerance test is completed if a pregnant client fails the 1-hour glucose tolerance test. A chest x-ray is required after 20 weeks of gestation if the client has a positive TST. Vaginal and anal cultures for GBS are obtained at 35 to 37 weeks of gestation.
Which immediate action would the nurse take if a client in the active phase of labor says, "I feel all wet. I think I wet myself."? A. Give her the bedpan B. Change the bed linens C. Inspect her perineum D. Take an oral temperature
Answer: C Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.
When the fetal monitor is applied to a client's abdomen, it records late decelerations. Which action would the nurse take? A. Notify the health care provider. B. Elevate the head of the bed. C. Reposition the client on her left side. D. Administer oxygen by the way of facemask.
Answer: C Late decelerations may indicate impaired placental perfusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the health care provider is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.
Which instruction would the nurse include when teaching episiotomy care? A. Rest with legs elevated at least 2 times a day. B. Avoid stair climbing for several days after discharge. C. Perform perineal care after toileting until healing occurs. D. Continue sitz baths 3 times a day if they provide comfort.
Answer: C Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.
Which is the immediate nursing action when a client's membranes rupture spontaneously, releasing clear, odorless fluid? A. Change the bedding. B. Notify the practitioner. C. Assess the fetal heart rate (FHR). D. Obtain the client's blood pressure.
Answer: C The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, addressing comfort by changing the bedding is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.
Which condition is detected by an alpha-fetoprotein test? A. Kidney defects B. Cardiac anomalies C. Neural tube defects D. Urinary tract anomalies
Answer: C The alpha-fetoprotein test detects neural tube defects, Down syndrome, and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.
When assessing a client who gave birth 1 day ago, the nurse finds the fundus is firm at 1 fingerbreadth below the umbilicus and the perineal pad is saturated with lochia rubra. Which is the nurse's next action? A. Recording these expected findings B. Obtaining a prescription for an oxytocic medication C. Asking the client when she last changed the perineal pad D. Notifying the primary health care provider of excessive bleeding
Answer: C The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia, so asking the client when she last changed the perineal pad is appropriate. These findings cannot be supported or recorded without additional information. Excessive bleeding cannot be established without more information from the client. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus.
Which is the nurse's first action when a client in active labor starts screaming, "The baby is coming! Do something!"? A. Notify the practitioner of the imminent birth. B. Tell the client that it is too soon and encourage her to pant. C. Check the perineal area for visibility of the presenting part. D. Help the client hold her knees together and explain what to expect.
Answer: C The first action by the nurse would be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse would remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.
The fetus of a client in labor is found to be at +1 station. Where would the nurse locate the presenting part? A. On the perineum B. High in the pelvis C. Just below the ischial spines D. Slightly above the ischial spines
Answer: C The term station is used to indicate the location of the presenting part. The level of the tip of the ischial spines is considered 0 station. The position of the bony prominence of the fetal head is described in centimeters minus (above the spines) or plus (below the spines). Just below the ischial spines is a +1 station. On the perineum, referred to as crowning, is designated as +5. High in the pelvis is indicated by the term floating, which means that the presenting part has not yet engaged in the pelvis. A station of -1 indicates that the head is just above the ischial spines.
Which type of lochia would the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? A. Scant alba B. Scant rubra C. Moderate rubra D. Moderate serosa
Answer: C The uterus sloughs off the blood, tissue, and mucus of the endometrium postdelivery. This happens in 3 stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that is expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for about 7 days. Lochia serosa is the second stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts about 2 weeks, although for some women it can last up to 4 to 6 weeks postpartum. Lochia alba is the final stage of lochia; rather than blood, you will see a white or yellowish discharge that is generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around 6 weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than 2 weeks.
Which problem is suggested when a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity followed by fundal tenderness and a small amount of dark-red bleeding? A. True labor B. Placenta previa C. Partial abruptio placentae D. Abdominal muscular injury
Answer: C Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.
A prenatal client's vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client's clinical record? A. Hegar B. Goodell C. Chadwick D. Braxton-Hicks
Answer: Chadwick A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton-Hicks contractions, can be felt through the abdominal wall.
When can a primigravida fetal heartbeat be heard for the first time? A. A stethoscope at 4 weeks B. A fetoscope at 10 to 12 weeks C. Doppler ultrasound after 20 weeks D. Doppler ultrasound at 10 to 12 weeks
Answer: D A fetal heartbeat can be obtained at 10 to 12 weeks with electronic Doppler ultrasound. The heartbeat cannot be obtained with a stethoscope, and 4 weeks is too early to hear a fetal heart. A fetoscope cannot pick up the heartbeat until the 17th week. The heart rate can be detected 8 to 10 weeks earlier than 20 weeks.
Which statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? A. "I will take a cool shower before each feeding." B. "I will drink a couple of quarts of fat-free milk a day." C. "I will wear a snug-fitting breast binder day and night." D. "I will apply warm packs and massage my breasts before each feeding."
Answer: D Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed.
A client at 36 weeks' gestation presents with severe abdominal pain, heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication of pregnancy is suggested by these signs and symptoms? A. Hydatidiform mole B. Vena cava syndrome C. Marginal placenta previa D. Complete abruptio placentae
Answer: D Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.
Which descriptor would the nurse use when explaining to a client how to time the frequency of contractions? A. From the end of 1 contraction to the end of the next contraction B. From the end of 1 contraction to the beginning of the next contraction C. From the beginning of 1 contraction to the end of the next contraction D. From the beginning of 1 contraction to the beginning of the next contraction
Answer: D The frequency of contractions is timed from the beginning of 1 contraction to the beginning of the next; this is the definition of 1 contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of 1 contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of 1 contraction to the end of the next contraction is too long a time frame and will produce inaccurate information.
Which instruction would the nurse give to a client in labor who begins to experience dizziness and tingling of her hands? A. Breathe into her cupped hands. B. Pant during the next 3 contractions. C. Hold her breath with the next contraction. D. Use a fast, deep, or shallow breathing pattern.
Answer: A Dizziness and tingling of the hands are signs of respiratory alkalosis, most likely the result of hyperventilating. Breathing into cupped hands or a paper bag promotes the rebreathing of carbon dioxide. Panting during the next 3 contractions could cause the client to hyperventilate more. Holding her breath with the next contraction will not improve the client's respiratory alkalosis. Using a fast, deep, or shallow breathing pattern could cause the client to hyperventilate more.
Which factor will increase the risk for hypotonic uterine dystocia in a postpartum client? A. Twin gestation B. Gestational anemia C. Hypertonic contractions D. Gestational hypertension
Answer: A A multiple gestation thins the uterine wall by overstretching it; therefore the efficiency of contractions is reduced. Gestational anemia is physiological anemia that is benign; although anemia may cause fatigue during labor, it does not affect uterine contractility. Hypertonic contractions will cause increased discomfort, fatigue, dehydration, and increased emotional distress, not hypotonic uterine dystocia. Therapeutic interventions include rest and sedation. Gestational hypertension may trigger preterm labor; it does not cause hypotonic uterine dysfunction.
Which effect does the nurse expect after an amniotomy is performed on a client in active labor? A. Diminished vaginal bleeding B. Less discomfort with contractions C. Progressive dilation and effacement D. Increased maternal and fetal heart rates
Answer: C Amniotomy permits more effective pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Discomfort may increase because contractions usually become more intense after amniotomy. Amniotomy should not affect maternal and fetal heart rates.
Which intervention would the nurse initiate when a fetal heart pattern signifying uteroplacental insufficiency occurs? A. Inserting a urinary catheter B. Administering oxygen by means of nasal cannula C. Helping the client turn to the side-lying position D. Encouraging the client to pant with her next contraction
Answer: C Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urinary catheter is unnecessary; in addition, it requires a primary health care provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action? A. Administering oxygen B. Elevating the head of the bed C. Drawing blood for a hematocrit level D. Giving an intramuscular analgesic
Answer: A Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary health care provider's prescription.
Which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beats over the baseline rate of 135 beats per minute that lasts 15 seconds? A. An acceleration B. An early increase C. A sonographic motion D. A tachycardic heart rate
Answer: A An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats per minute.
After a client gives birth, which physiological occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled? A. Relaxation of the uterus B. Descent of the uterus in the abdomen C. Appearance of a sudden gush of blood D. Retraction of the umbilical cord into the vagina
Answer: C When the placenta separates from the uterine wall, it tears blood vessels, resulting in a gush of blood from the vagina. The uterus should become firm when the placenta begins to separate. The fundus rises in the abdomen when the placenta separates. The cord does not retract into the vagina; in fact, the reverse occurs: As the placenta separates it descends into the vaginal introitus, after which the umbilical cord appears longer and protrudes from the vagina.
Which test is used to confirm cephalopelvic disproportion? A. Ultrasound B. Fetal scalp pH C. Amniocentesis D. Digital pelvimetry
Answer: A A sonogram of the pelvis is an accurate and safe test for cephalopelvic disproportion. Fetal scalp pH is performed to assess fetal well-being. Amniocentesis is a test of the components of the amniotic fluid; it does not reveal the size of the fetus or the diameter of the pelvis. Digital pelvimetry is an external measurement obtained by the primary health care provider; it is an estimate, not an accurate assessment, and is used less commonly than ultrasound.
Which cervical changes are observed during pregnancy? Select all that apply. One, some, or all responses may be correct. A. The cervical tip becomes soft B. The fragility of cervical tissues decreases. C. The volume of cervical muscle increases. D. The external cervical os appears as a jagged slit. E. The elasticity of cervical collagen-rich connective tissue increases
Answers: A, C, & E By the beginning of the sixth week of pregnancy, the cervical tip softens. During pregnancy, the cervical muscle and its collagen-rich connective tissues increase in volume and become loose and highly elastic. Cervical tissue fragility also increases. The external cervical os appears as a jagged slit postpartum; however, it does not during pregnancy.
When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action would the nurse implement at this time? A. Having her pant-blow during contractions B. Placing her legs in stirrups to facilitate pushing C. Encouraging her to bear down with each contraction D. Reviewing the pushing techniques taught in childbirth classes
Answer: A Although there are exceptions, the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing. Pushing may cause cervical trauma when the cervix is not completely dilated. It is too early to prepare for the second stage of labor or to have the client bear down with each contraction if the cervix is not fully dilated. At this time the client is completely introverted and will be unreceptive to a review of pushing techniques.
Which type of isolation precautions would the postpartum nurse plan to institute for a client who has delivered her infant by cesarean birth because of active genital herpes? A. Enteric B. Droplet C. Contact D. Airborne
Answer: C Contact precautions include a gown, mask, and gloves to protect the nurse from the virus; the client should be in a private room. The Centers for Disease Control and Prevention guidelines for isolation precautions do not include enteric precautions as a category. Droplet and airborne precautions are not necessary for a person with genital herpes.
Which assessment would the nurse include in the plan of care for a postpartum client with large, painful varicose veins? A. Monitoring daily clotting times B. Assessing for peripheral pulses C. Monitoring daily hemoglobin values D. Assessing for signs of thrombophlebitis
Answer: D Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.
A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8°F (38.2°C), chills, and malaise. Which condition would the nurse suspect? A. Mastitis B. Engorgement C. Blocked milk duct D. Inadequate milk production
Answer: A Because of the presence of generalized symptoms, the nurse would suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced.
Which is a primary focus of teaching for a pregnant adolescent at her first prenatal clinic visit? A. Instructing her about the care of an infant B. Informing her of the benefits of breast-feeding C. Advising her to watch for danger signs of preeclampsia D. Encouraging her to continue regularly scheduled prenatal care
Answer: D It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.
Which food contains at least 100 mcg of folate per serving? Select all that apply. One, some, or all responses may be correct. A. Bread B. Broccoli C. Cooked pasta D. Black-eyed peas E. Ready-to-eat breakfast cereal
Answer: D & E Neural tube defects (NTDs), or failures in closure of the neural tube, are more common in infants of women with poor folic acid intake. Proper closure of the neural tube is required for normal formation of the spinal cord, and the neural tube begins to close within the first month of gestation, often before a person realizes she is pregnant. Therefore, all people who are capable of becoming pregnant should take 0.4 mg of folic acid every day, in addition to consuming dietary sources of folate. One-half cup of black-eyed peas contains at least 100 mcg of folate. Ready-to-eat breakfast cereal contains 200 mcg of folate. A slice of bread contains 20 mcg, not 100 mcg of folate. One-half cup of broccoli and a cup of pasta contain 50 mcg, not 100 mcg of folate.
Thirty minutes after initiation of epidural anesthesia the fetus is experiencing late decelerations. List the following nursing actions in order of priority. 1.Reposition client on her side. 2.Increase intravenous fluids. 3.Notify the healthcare provider if late decelerations persist. 4.Reassess the fetal heart rate (FHR) pattern. 5.Document interventions and related maternal/fetal responses.
Answer: 1, 2, 4, 3, 5 Repositioning the client to the side increases uterine blood flow, improves cardiac output, and takes the pressure exerted by the uterus off the vena cava. Increasing the delivery of fluids augments uterine blood flow and improves cardiac output. Reassessing the FHR pattern enables the nurse to determine whether the FHR has returned to a safe level without reflex late decelerations. Persistent late decelerations are a non-reassuring fetal sign; the health care provider should be informed. Documentation of interventions and client responses ensures that information is included in the client's legal clinical record and communicated to other care providers.
Which information would tell the nurse if a woman at 40 weeks' gestation having contractions is in true labor? A. The cervix dilates and becomes effaced in true labor. B. Bloody show is the first sign of true labor. C. The membranes rupture at the beginning of true labor D. Fetal movements lessen and become weaker in true labor.
Answer: A The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.
Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? A. Pica B. Caffeine intake C. Alcohol abuse D. Artificial sweetener use
Answer: A The practice of pica, especially the ingestion of heavy metals, must be considered when pregnant women are found to be anemic. Caffeine, alcohol, and artificial sweeteners are not directly linked to anemia in pregnant women.
Between contractions that are 2 to 3 minutes apart and last about 45 seconds the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. Which is the priority nursing action? A. Notify the health care provider. B. Resume continuous fetal heart monitoring. C. Continue to monitor the maternal vital signs. D. Document the fetal heart rate as an expected response to contractions.
Answer: A The expected FHR is 110 to 160 beats/min between contractions. An FHR of 100 beats/min is bradycardia (baseline FHR slower than 110 beats/min) and indicates that the fetus may be compromised, requiring notifying the health care provider and medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. Although a fetal heart rate slower than 110 beats/minute should be documented, it is not an expected response.
Which physiological changes would the nurse anticipate after an amniotomy is performed? A. Diminished bloody show B. Increased and more variable fetal heart rate C. Less discomfort with contractions D. Progressive dilation and effacement
Answer: D Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding (bloody show) may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after the membranes are artificially ruptured.
Cramping and vaginal spotting occurring at 12 weeks' gestation in conjunction with a closed cervix is characteristic of which problem? A. Missed abortion B. Inevitable abortion C. Incomplete abortion D. Threatened abortion
Answer: D Because the cervix is closed, this is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion. Once the cervix is dilated abortion is inevitable. Portions of the products of conception will have to be passed for a diagnosis of incomplete abortion.
Which direction would the nurse give a client in preparation for ultrasonography at the end of her first trimester? A. Empty her bladder B. Avoid eating for 8 hours C. Take a laxative the night before the test D. Increase fluid intake for 1 hour before the procedure.
Answer: D In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation, so directing the client to not eat for 8 hours before the test or to take a laxative would not be appropriate.
For which reason would the nurse encourage a client to void during the first stage of labor? A. A full bladder is often injured during labor. B. A full bladder may inhibit the progress of labor. C. A full bladder jeopardizes the status of the fetus. D. A full bladder predisposes the client to urinary infection.
Answer: B A full bladder inhibits the progress of labor by encroaching on the uterine space and impeding the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.
In the second hour after the client gives birth, her uterus is firm, above the level of the umbilicus, and to the right of midline. Which nursing action is an appropriate response to this situation? A. Having the client empty her bladder B. Watching for signs of retained secundines C. Massaging the uterus vigorously to prevent hemorrhage D. Explaining to the client that this is a sign of uterine stabilization
Answer: A A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. The bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not accurate; the uterus will not remain contracted over a full bladder.
Which is the priority nursing intervention for the postpartum client whose fundus is 3 fingerbreadths above the umbilicus, boggy, and midline? A. Massaging the uterine fundus B. Helping the client to the bathroom C. Assessing the peri-pad for the amount of lochia D. Administering intramuscular methylergonovine (Methergine) 0.2 mg
Answer: A A uterus that is displaced and above the umbilicus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine (Methergine) is administered.
Which cardiac disease has the lowest risk for maternal mortality? A. Endocarditis B. Aortic stenosis C. Patent ductus arteriosus D. Pulmonary hypertension
Answer: C A client with patent ductus arteriosus has the lowest risk for maternal mortality. A client with aortic stenosis has a higher risk of maternal mortality. A client with endocarditis or pulmonary hypertension has the highest risk of maternal mortality.
Which client statement indicates understanding of teaching about a nonstress test? A. "I'll need to have an intravenous (IV) line so the medication can be injected before the test." B. "My baby may get very restless after I have this test." C. "I hope this test doesn't cause my labor to start too early." D. "If the heart reacts well, my baby should do OK when I give birth."
Answer: D The nonstress test is used to evaluate the response of the fetus to movement and activity. A reactive test indicates that the fetus is healthy. No injections of any kind are used during a nonstress test; it involves only the use of a fetal monitor to record the fetal heart rate during periods of activity. The nonstress test will not influence the activity of the fetus because no exogenous stimulus is used. Early labor is unlikely because the nonstress test is noninvasive.
Which is a sensory simulation strategy a laboring client can use as a nonpharmacological strategy for pain management? A. Gentle massage of the abdomen B. Biofeedback-assisted relaxation techniques C. Application of a heat pack to the lower back D. Selecting a focal point and beginning breathing techniques
Answer: D Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.
Which action would the nurse take when a client who is performing patterned, paced breathing during the transition phase of labor experiences tingling and numbness of the fingertips? A. Tell the client to breathe into a paper bag. B. Place an oxygen mask over the client's face. C. Call the primary health care provider to report the client's response. D. Instruct the client to begin taking slow, deep breaths.
Answer: A A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation. The client's oxygen level is increased; the client needs to increase the carbon dioxide level and decrease the oxygen level. The client should rebreathe her own exhalations first; if alkalosis persists, more intensive treatment may be needed. There is no need to place an oxygen mask over the client's face because the client already has an increased level of oxygen, nor is it necessary to call the primary health provider to report the client's response. Carbon dioxide is too dilute in room atmosphere; deep breaths will not resolve the alkalosis.
