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Labor and Delivery


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A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time?
A. Impaired urinary elimination related to the effects of the epidural
Rationale: The highest priority of care for the client receiving an epidural anesthetic is monitoring blood pressure and preventing hypotension, which is a frequent complication of regional anesthesia. I.V. fluids are given before the epidural agent to increase blood volume and cardiac output and to minimize hypotension. Although impaired urinary elimination is a potential problem, it isn't the highest priority. Deficient knowledge doesnÂ’t take priority over the risk for injury. Impaired skin integrity is unlikely because the labor client is typically healthy and the amount of time the client remains in bed doesn't cause skin breakdown.
A neonate born 18 hours ago with meningomyelocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?
A. Preventing infection
B. Ensuring adequate hydration
C. Pro
A Rationale: Preventing infection is the nurse's primary preoperative goal for a neonate with meningomyelocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.
Which of the following correctly defines puerperium?
A. The 1st hour after birth
B. The 6 weeks following birth
C. The days spent in the hospital
D. The duration of breast-feeding
b Rationale: Puerperium is defined as the 6 weeks postpartum. The other options are incorrect.
An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large neonates, to shorten the second stage of labor, or for a malpresentation. The nurse caring for the mother following an assisted birth should keep wh
a Rationale: When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the neonate than a forceps delivery. Cephalohematomas occur more often in assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period.
The nurse is aware that periodic relaxation and contraction of the uterine muscles cause pains and cramping after birth. Which of the following clients is more likely to experience severe pain after giving birth?
A. A gravida 1 para 1001 client wh
b Rationale: The client who is the second-time mother and breast-feeding will experience more pain and cramping after giving birth. In first-time mothers, the uterine tone is increased, so the fundus remains firm, thereby decreasing the incidence of uterine cramping. In subsequent pregnancies, uterine tone decreases and cramping increases as the uterine muscles contract. Mothers who breast-feed experience more pain and cramping after giving birth. Breast-feeding initiates the release of the hormone oxytocin from the pituitary gland. Oxytocin causes uterine contractions to be strengthened and coordinated so that the uterus remains very firm.
The nurse should tell new mothers who are breast-feeding that breast milk is produced when:
A. the placenta is delivered, causing the secretion of prolactin.
B. the neonate begins to suckle and stimulates the anterior pituitary to produce p
a Rationale: Delivery of the placenta causes the secretion of prolactin, which in turn produces breast milk. Thus, retained placental fragments can interfere with the production of milk. When the neonate sucks at the breast, the hypothalamus stimulates the production of prolactin-releasing factor, which further stimulates active production of prolactin to maintain milk production; sucking, however, doesn't initiate prolactin secretion. Oxytocin acts to constrict milk glands and push milk forward in the ducts that lead to the nipple. The role of relaxin is unknown.
When performing a nursing assessment of a client's episiotomy, the nurse would especially assess for:
A. location.
B. discharge and odor.
C. edema and approximation.
D. subinvolution.
c Rationale: Episiotomies should be assessed for edema and approximation of the incision. An edematous perineum causes more tension of the suture line and increases pain. Although the sutures may be difficult to visualize, the suture line should be intact. Episiotomy location is important but not as important as the presence of edema. Discharge and odor refer to an assessment of the lochia. Subinvolution refers to the complete return of the uterus to its prepregnancy size and shape.
The nurse is teaching a group of couples in a childbirth class. After the nurse describes normal labor, including the premonitory signs of labor, the clients attending the class comment. Which of the following remarks would indicate that further teaching
a Rationale: A class member saying her membranes won't rupture until she's ready to deliver is an indication that further teaching is necessary. Most clients' membranes will rupture before the time of delivery, but approximately 12% will rupture before the onset of labor. Premonitory signs of labor include Braxton Hicks contractions; lightening (which usually occurs 2 weeks before labor begins in a first pregnancy); cervical changes, including the softening and ripening; bloody mucus vaginal discharge (bloody show); rupture of the membranes; a sudden burst of energy; weight loss; increased backache; and diarrhea, indigestion, nausea, or vomiting.
The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
A. "Now isn't a good time to begin dieting becaus
c Rationale: Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or baby needs; they work in congruence with a balanced diet.
When caring for a client who has had a cesarean birth, which action is inappropriate?
A. Removing the initial dressing for incision inspection
B. Monitoring pain status and providing necessary relief
C. Supporting self-esteem concern
a Rationale: Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.
When caring for a client who is a primigravida, the nurse would expect that the second stage would normally last how long?
A. Approximately 2 hours
B. Less than 1 hour
C. 4 hours
D. 3 hours
a Rationale: The average length of time a primigravida needs to push is approximately 2 hours. Longer than that might mean the client is experiencing an arrest in descent. Few primigravidas have a second stage of labor shorter than 1 hour.
At 32 weeks' gestation, a client is admitted to the hospital with a diagnosis of pregnancy-induced hypertension. Based on this diagnosis, the nurse expects assessment to reveal which sign?
A. Edema
B. Fever
C. Glycosuria
D. Vo
a Rationale: Classic signs of pregnancy-induced hypertension include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with any number of disorders.
During the postpartum period, the nurse should assess for signs of normal involution. Which of the following would indicate that the client is progressing normally?
A. The uterus is descending at the rate of one fingerbreadth per day.
B. Bl
a Rationale: During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood pressure doesn't change during the postpartum period. Urine output typically increases after delivery. Usually, the client will need six to seven perineal pads per day at this time.
For a client who is fully dilated, which of the following actions would be inappropriate during the second stage of labor?
A. Positioning the mother for effective pushing
B. Preparing for delivery of the baby
C. Assessing vital signs
d Rationale: In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.
Which of the following would not be an indication of placental detachment?
A. An abrupt lengthening of the cord
B. An increase in the number of contractions
C. Relaxation of the uterus
D. Increased vaginal bleeding
c Rationale: Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.
The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:
A. the delivery may need to be induced early.
B. the bi
Rationale: Early induction or early cesarean section is possible if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary.
Which of the following situations is more likely to predispose a client to postpartum hemorrhage?
A. Birth of a 3,175-g (7 lb) infant
B. Birth of twins
C. Prolonged first stage of labor
D. Pregnancy-induced hypertension (PIH)
b Rationale: Multiple gestation causes overdistention of the abdomen, which can lead to uterine atony and, thus, uterine hemorrhage. A weight of 3,175 g (7 lb) is classified as normal for an infant. A macrocosmic infant (4,000 g [8 lb, 13½ oz]) could cause uterine atony. Neither long labor nor PIH causes postpartum hemorrhage.
After explaining to the client about Lamaze classes, the nurse determines that the client has understood the instructions when the client says that the:
A. classes promote birth in a tub of warm water.
B. framework for the Lamaze method is
b Rationale: The client has understood the nurse's instructions when the client says that the framework for the Lamaze method is the fear-tension-pain cycle. Lamaze classes don't promote birth in a tub of water or vaginal birth after cesarean delivery, and they don't rely on the client receiving epidural anesthetic.
Which behavior would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
A. An increased sense of rectal pressure
B. A decrease in intensity of contractions
C. An increase in
a Rationale: An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.
Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?
A. A neonate who is in good condition
B. A neonate who is mildly depressed
C. A neonate who is moderately depressed
D. A neon
a Rationale: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.
The nurse is caring for a client with a midline episiotomy and a third-degree laceration. The nurse understands that this type of laceration:
A. extends into the anterior wall of the rectum.
B. extends to the perineal skin and other superfi
c Rationale: Lacerations are tears that occur during childbirth. A third-degree laceration extends into the anal sphincter muscle. A first-degree laceration is limited to the perineal skin and other superficial structures such as the labia. A second-degree laceration reaches the perineal muscles, and a fourth-degree laceration involves the anterior rectal wall.
Which of the following would be inappropriate to assess in a mother who is breast-feeding?
A. The attachment of the neonate to the breast
B. The mother's comfort level with positioning the neonate
C. Audible swallowing
D. The
d Rationale: Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A neonate who is smacking his lips isn't well attached and can injure the mother's nipples.
A multigravida at 36 weeks' gestation visits the emergency department because her boyfriend has beaten her severely. The first nursing intervention should be to:
A. contact the authorities.
B. ensure the client's safety.
C. identify
b Rationale: The first nursing intervention is to ensure the client's safety because these clients are terrified that the abuser will arrive and continue the cycle of violence. After this has been done, the nurse can contact the authorities, identify a support person, and ensure confidentiality. Photographing the client's injuries requires the client's consent.
A client who is 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps?
A. Suggesting that she walk for 1 hour twice per day
B. Advising her to take over-the-
c Rationale: Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours per day during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a balanced diet, calcium supplements or additional servings of high-calcium foods may be unnecessary.
A client who is planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse's best response?
A. "Pregnancy is a human process; you don't have to worry."
B. "You pra
d Rationale: When counseling a client who is planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The nurse should provide information but not prescribe the drug. It's the client's responsibility to ask the health care provider about a prescription. Telling the client not to worry ignores the client's needs. Practicing good health habits is important for any person. Telling the client that it's up to nature is inaccurate.
Which instructions should the nurse give to a client who is 26 weeks pregnant and complains of constipation?
A. Encourage her to increase her intake of roughage and to drink at least six 8 oz glasses of water per day.
B. Tell her to ask her
a Rationale: The best instruction is to encourage the client to increase her intake of high-fiber foods (roughage) and to drink at least six glasses of water per day. Mild laxatives and stool softeners may be needed, but dietary changes should be tried first. Straining during defecation and diarrhea can stimulate uterine contractions, but telling the client to go to the evaluation unit doesn't address her concern.
It has been 6 hours since a client's initial voiding following an uncomplicated vaginal delivery. The nurse assesses her fundus to be 3 cm above the umbilicus and deviated to the right side. The nurse has an order to catheterize this client if she's unab
a Rationale: The nurse should catheterize the client if she measures 100 ml of urine. A voiding of 300 ml or less is a sign of urine retention. Other signs of urine retention include increased lochia flow and a dull sound upon percussion of the suprapubic area. The sound should be hollow if the bladder isn't full. Initial voiding of 350 ml is borderline in making an assessment of urine retention. The nurse should assess for other signs of urine retention. Initial voiding of 400 or 500 ml is within an acceptable range.
A client diagnosed with gestational diabetes has been admitted for induction of labor at 38 weeks. The client tells the nurse, "My previous labors started on their own. How will this induction of labor be different from my last labor?" Upon whi
Rationale: The goal during induction of labor is to produce a contractile pattern similar to that observed in spontaneous labor. The infusion of oxytocin is increased until a contractile pattern is achieved in which the contractions occur every 2 to 3 minutes with a duration of 40 to 60 seconds in a 10-minute period and the uterus relaxes between contractions. One of the complications of an induction is the risk of uterine rupture. The client scheduled to receive oxytocin is monitored for at least 20 minutes before initiation of the drug to establish a baseline fetal heart rate. Thereafter, the client is monitored in the same way as a client in spontaneous labor, which depends on the maternal and fetal responses to labor.
Labor is divided into how many stages?
A. Five
B. Three
C. Two
D. Four
d Rationale: Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition.
A client at 40 weeks' gestation is admitted to the labor unit in active labor. She's examined by the nurse, who documents the following data: cervix, 9 cm, right occipitoanterior; and station, +2. The nurse determines that the client is in which stage of
a Rationale: The client is in the first stage of labor. The primary criterion differentiating the stages of labor is the progression of cervical dilation. The first stage of labor is from no dilation to complete dilation. The second stage of labor begins with complete dilation and ends with delivery of the baby. The third stage is the period after the delivery of the baby up to and including the delivery of the placenta. The fourth stage is immediately postdelivery, or postpartum.
Which nursing diagnosis would the nurse anticipate as having the highest priority for the client with gestational diabetes in labor?
A. Risk for infection related to invasive procedures during labor
B. Risk for injury to fetus related to th
Rationale: The priority for care would be to monitor the fetal response to the contractions because pregnancy may have accelerated the progress of vascular disease. The gestational diabetic is at higher risk for the development of preeclampsia, therefore increasing the risk of uteroplacental insufficiency. All of the remaining nursing diagnoses are appropriate for the gestational diabetic during labor, but the priority remains close observation of the client's glucose level and the fetal response to labor contractions.
A neonate has vesicular lesions on the soles and palms, red rash around the mouth and anus, and is small for gestational age. The neonate has contracted which sexually transmitted disease from the mother?
A. Syphilis
B. Gonorrhea
a Rationale: These symptoms, together with appropriate serologic tests, indicate congenital syphilis. Gonorrhea would be indicated by ophthalmia neonatorum. Rubella isn't a sexually transmitted disease. Neonates affected with Type 2 herpes manifest jaundice, seizures, increased temperature, and characteristic vesicular lesions.
A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be least likely if the neonate developed neonate hemolytic disease?
A. Lethargy or irritability
B. Poor feeding pa
c Rationale: Although weight loss may be greater than 10%, the most important assessments must include those addressing the problem of a rising bilirubin. Neonates who develop severe jaundice as a result of Rh and ABO incompatibility will exhibit lethargy or irritability and poor feeding patterns. If bilirubin levels are high enough to cross the blood brain barrier (usually 20 mg and higher), the neonate is at serious risk for neurologic impairment due to permanent cell damage (kernicterus).
Prevention of preterm births is vital for which reason?
A. It's costly to care for these neonates.
B. Preterm birth causes more than half of the neonatal deaths in the United States.
C. These neonates usually wind up with long-term h
b Rationale: Prematurity is the leading cause of neonatal deaths in the United States; other industrialized nations have fewer premature births and fewer neonatal deaths than the United States does. Although the other three answers are complications of prematurity, prevention is the outcome nurses must focus on while providing care to their clients.
When teaching a group of pregnant teens about reproduction and conception, the nurse is correct when stating that fertilization occurs:
A. in the uterus.
B. when the ovum is released.
C. near the fimbriated end.
D. in the firs
d Rationale: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.
The nurse is caring for a primigravida who is scheduled for a fetal acoustic stimulation test (FAST). The nurse should explain to the client that the primary purpose of this test is to:
A. induce contractions.
B. induce fetal heart rate acc
b Rationale: The FAST is being used more commonly. This noninvasive technique induces fetal heart rate accelerations by using low-frequency vibrations on the maternal abdomen over the fetal head. It can shorten the length of the nonstress test. The FAST isn't used to induce contractions, shorten the length of the contraction stress test, or determine fluid volume.
Which of the following would be least likely to indicate anticipated bonding behaviors by new parents?
A. The parents' willingness to touch and hold the neonate
B. The parents' expression of interest about the size of the neonate
d Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the neonate, expressing interest about the neonate's size, and indicating a desire to see the neonate are behaviors indicating parental bonding.
A client has come to the clinic for her first prenatal visit. The nurse should include which statement about using drugs safely during pregnancy in her teaching?
A. "During the first 3 months, avoid all medications except ones prescribed by y
d Rationale: Because all medications can be potentially harmful to the growing fetus, telling the client to consult with her health care provider before taking any medications is the best teaching. The client needs to understand that any medication taken at any time during pregnancy can be teratogenic.
A multigravida at 37 weeks' gestation tells the nurse that she has frequent heartburn. After providing the client with suggestions for obtaining relief from the heartburn, the nurse determines that the client has understood the instructions when she says
d Rationale: The client who complains of heartburn should eat smaller, more frequent meals with fluids. Baking soda in water should be avoided because of the sodium in baking soda. Large meals and fried foods should also be avoided.
The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling this client's blood glucose levels, so she has started insulin therapy.
b Rationale: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily.
While caring for a healthy neonate female, the nurse notices red stains on the diaper after the neonate voids. Which of the following should the nurse do next?
A. Call the physician to report the problem.
B. Encourage the mother to feed the
c Rationale: Female neonates may have some vaginal bleeding in the 1st or 2nd day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician doesn't need to be called. This bleeding is normal and doesn't indicate dehydration or hematuria.
Lochia normally progresses in which pattern?
A. Rubra, serosa, alba
B. Serosa, rubra, alba
C. Serosa, alba, rubra
D. Rubra, alba, serosa
Rationale: As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.
Which of the following describes the rationale for administering vitamin K to every neonate?
A. Neonates don't receive the clotting factor in utero.
B. The neonate lacks intestinal flora to make the vitamin.
C. It boosts the minimal
b Rationale: Neonates are at risk for bleeding disorders during the 1st week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K, which is necessary for blood coagulation. Vitamin K stimulates the liver to produce clotting factors. Vitamin K doesn't prevent PKU, which is an inherited metabolic disease.
As she tries to decide on a birth-control method, a client requests information about medroxyprogesterone (Depo-Provera). Which of the following represents the nurse's best response?
A. Depo-Provera needs to be administered every 12 weeks.
a Rationale: Depo-Provera will provide effective birth control for 3 months, and it may be the birth-control method of choice for clients who are breast-feeding because studies haven't established any contraindications. There is no evidence that the drug has a high failure rate.
A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next?
A. C
c Rationale: Fetal well-being is determined during a nonstress test by two accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the outcome of a nonstress test.
Which of the following would be inappropriate to include in the plan of care for a client during the fourth stage of labor?
A. Vital signs and fundal checks every 15 minutes
B. Time with the neonate to initiate breast-feeding
C. Cath
c Rationale: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the plan of care during the fourth stage of labor.
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?
A. Applying cold to limit edema during the first 12 to 24 hours <
b Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.
A 34-year-old client is 34 weeks pregnant and is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which nursing intervention should the nurse perform?
A. Allow the client to ambulate
c Rationale: Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute, therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.
A 28-year-old client gave birth 1 hour ago to a full-term male neonate. Which finding should the nurse expect when palpating the client's fundus?
A. Soft, at the level of the umbilicus
B. Firm, ¨ú¡È (1.9 cm) below the umbilicus
c Rationale: Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well because of such factors as a full bladder or retained pieces of placenta, and places the postpartum client at risk for hemorrhage.
The nurse applies a fetal monitor to a 15-year-old primagravida admitted to the hospital with possible pregnancy-induced hypertension. Which monitor pattern would the nurse expect to observe if the client is experiencing uteroplacental insufficiency?
a Rationale: Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression, and variable deceleration is caused by umbilical cord compression. Fetal acceleration is a sign of fetal well-being.
Which of the following would the nurse expect to assess as presumptive signs of pregnancy?
A. Amenorrhea and quickening
B. Uterine enlargement and Chadwick's sign
C. A positive pregnancy test and a fetal outline
D. Braxton Hic
Rationale: Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators — for example, uterine enlargement, Chadwick's sign, a positive pregnancy test, Braxton Hicks contractions, and Hegar's sign. Positive signs and objective indicators such as fetal outline on ultrasound confirm pregnancy.
During a home visit, the client, a single multigravida at 32 weeks' gestation, tells the nurse that she craves and often eats laundry starch for lunch and usually has a bowl of soup for supper. Total weight gain to date has been 12 lb (5 kg). A priority
c Rationale: The priority nursing diagnosis is Imbalanced nutrition: Less than body requirements related to pica. Pica is the term used when clients eat products that aren't meant for consumption. The client has gained only 12 lb to date, which is below the recommended average. No evidence exists to suggest impaired parenting, ineffective coping, or noncompliance related to insufficient resources.
Which labor room assignment would the nurse give to a client diagnosed with pregnancy-induced hypertension?
A. Near the elevator so that she can be transported quickly
B. Across from the nurses' station so that she can be observed closely <
b Rationale: The client with a diagnosis of pregnancy-induced hypertension should be close to the nurses' station because she requires close observation. The client also should be placed in a room with decreased stimuli. Stimuli may bring on a seizure because of the client's central nervous system irritability. The back hallway room is quiet but doesn't allow close observation. The care needed by the client would be delivered on the labor unit; therefore, she wouldn't need to be transported until she delivered. Placement near the nursery would increase stimulation, which wouldn't be beneficial to the client.
To obtain a good monitor tracing on a client in labor, the mother lies on her back. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which of the following should be the nurse's first action?
A. Reposition the client to her
a Rationale: This client is hypotensive because of decreased blood flow through the aorta. By turning the client to her left side, the nurse removes the weight of the uterus from the aorta and increases the maternal blood flow. Taking blood pressure, summoning the physician, starting oxygen, and increasing I.V. fluids aren't necessary unless repositioning doesn't relieve the symptoms.
After delivering her second child, the client tells the nurse that she wants to breast-feed. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle-fed after 3 days of trying to nurse. Which of the following respons
b Rationale: One way to help support this client's wishes to breast-feed is to instruct her to room-in with her neonate so she can respond to the neonate's cues. Sending the neonate to the nursery lessens the mother's ability to learn her neonate's breast-feeding cues. The other options don't support the client's need for guidance.
A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following?
A. Excess sugar causing reduced placental functioning
B. Insulin acting as a growth hormone on the fetus
b Rationale: Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.
A multigravida tells the nurse that her husband has been experiencing nausea and vomiting and backaches that are similar to the client's discomforts during this pregnancy. The nurse should explain to the client that this is termed:
A. neurosis.
d Rationale: A partner who is very involved in the pregnancy occasionally experiences discomforts similar to those of pregnancy. This is termed "couvade." The partner isn't exhibiting neurosis, psychosis, or mimicry.
Twenty-four hours after birth, a neonate hasn't passed meconium. Noting this, the nurse suspects which condition?
A. Hirschsprung's disease
B. Celiac disease
C. Intussusception
D. An abdominal wall defect
a Rationale: Failure to pass meconium is an important diagnostic indicator for Hirschsprung's disease. Options B, C, and D aren't associated with failure to pass meconium.
When caring for a client during the second stage of labor, which action would be least appropriate?
A. Assisting the client with pushing
B. Ensuring the client's legs are positioned appropriately
C. Allowing the client clear liquids
c Rationale: During this time, the client is usually offered ice chips rather than clear liquids. Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate.
The nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:
A. take sleeping pills for a restful night's sleep.
B. try to get more rest by going to b
b Rationale: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now.
Which of the following functions would the nurse expect to be unrelated to the placenta?
A. Production of estrogen and progesterone
B. Detoxification of some drugs and chemicals
C. Exchange site for food, gases, and waste
D. P
d Rationale: Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.
Which of the following would be least likely to affect the parent-child relationship?
A. Readiness for the pregnancy
B. Nature of the pregnancy
C. Maturity of the parents
D. Grandparent support
d Rationale: Extended family is important to the social development of the infant but doesn't affect the parent-child relationship. Readiness for pregnancy, a healthy and uncomplicated pregnancy, and parental maturity are factors that promote a positive parent-child relationship.
A breast-feeding neonate will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex?
A. Tonic neck reflex
B. Moro's reflex
C. Grasp reflex
D. Rooting reflex
d Rationale: The rooting reflex is a neonate's response to having his cheek stroked. The neonate will turn his head to the side of the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The tonic neck reflex is elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side extend and those on the other side flex. Moro's reflex is the startle reflex. For example, when the neonate's crib is jolted, the neonate abducts his arms and extends them. The grasp reflex occurs when the neonate curls his fingers around another person's fingers.
When determining maternal and fetal well-being, which assessment is least important?
A. Signs of postural hypotension
B. Fetal heart rate and activity
C. The mother's acceptance of the growing fetus
D. Signs of facial or digit
a Rationale: Postural hypotension doesn't occur until late in the pregnancy and is easily correctable. Collection of other assessment data, such as fetal heart rate and activity, the mother's acceptance of the growing fetus, and signs of edema, should be started early in the pregnancy because abnormalities can put the mother or the fetus at risk for significant physiological and psychological problems.
A neonate receives an Apgar score at 1 and 5 minutes after birth. The 5-minute Apgar score is more predictive for which of the following?
A. Residual neurologic damage
B. Residual respiratory depression
C. Congenital heart defects
a Rationale: Apgar scores at 1 and 5 minutes after delivery estimate the severity of respiratory and neurologic depression. Studies have shown a high correlation between a low 5-minute Apgar score and the incidence of residual neurological damage. Apgar scores aren't used to determine the presence of congenital heart defects or the gestational age of the neonate.
The nurse is caring for a 35-year-old multipara who delivered a full-term infant by cesarean delivery because of a breech presentation. The nurse recognizes that which of the following events would be the most important contribution to preventing thrombo
d Rationale: Encouraging frequent ambulation would be the most important contribution to the prevention of thromboembolism. Clotting factors and fibrinogen are increased in the immediate postpartum period. When the client is in this hypercoagulable state, the vessel damage that occurs with birth and immobility predisposes her to developing thromboembolism. Although increasing oral fluid intake also is important, encouraging frequent ambulation is most important. Providing oxygen therapy and administering pain medications don't prevent thromboembolism formation.
When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
A. "I'll report increased frequency of urination."
b Rationale: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.
Which of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor?
A. Tetanic contractions
B. Elevated blood pressure
C. Early decelerations of fetal heart rate
D. Water i
a Rationale: Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration.
When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to imp
a Rationale: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.
When assessing a pregnant client with diabetes mellitus, the nurse is alert for signs and symptoms of a vaginal infection or urinary tract infection (UTI). Which condition makes this client more susceptible to such infections?
A. Electrolyte imbal
d Rationale: Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially Candida) and UTIs, because the hormonal changes of pregnancy affect the pH of the vagina and the urine. Electrolyte imbalances and hypoglycemia aren't associated with vaginal infections or UTIs. Insulin requirements may decrease in early pregnancy; however, as the client's food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise.
While caring for pregnant adolescents, the nurse should develop a plan of care that incorporates which health concern?
A. Age of menarche
B. Family and home life
C. Healthy eating habits
D. Level of emotional maturity
d Rationale: When assessing an adolescent initially, the nurse should try to determine the client's level of emotional maturity. This forms the basis for the nursing plan of care. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the client.
Which of the following is the most important aspect of nursing care in the postpartum period?
A. Supporting the mother's ability to successfully feed and care for her neonate
B. Involving the family in the teaching
C. Providing group
a Rationale: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on infant care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her infant takes priority.
After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6-lb (2.7-kg) weight gain, ascites, and pedal edema. This assessment indicates the client is:
b Rationale: Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing care includes emotional support to reduce anxiety and management of symptoms. These signs aren't normal reactions to ovulatory stimulants and aren't signs of pregnancy.
A 40-year-old at 37 weeks' gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which of the following complications is most likely causing the client's complaint of vaginal bleeding?
b Rationale: The major maternal adverse effects of cocaine use in pregnancy include spontaneous first trimester abortion and abruptio placentae. Placenta previa and ectopic pregnancy are also bleeding problems during pregnancy, but only abruptio placentae and placenta previa are third trimester complications.
When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do?
A. Observing for pooling of straw-colored fluid
B. Checking vaginal discharge with nitrazine paper
C. C
Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes.
During the admission assessment of a female neonate, the nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that:
a Rationale: Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the neonate's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is simply soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.
A 32-year-old primigravida who vaginally delivered a full-term infant without complication states that she would like to take a nap but allows the nurse to take vital signs and perform an assessment. According to Reva Rubin, the nurse recognizes that the
b Rationale: Reva Rubin describes the taking-in phase as a time when the postpartum mother needs to be mothered. For the first 24 hours after giving birth, the focus of the mother is on her own needs. She relies on others for this supportive care. In the taking-hold phase, the focus is on the baby and self-care activities for herself. This phase begins after 24 hours and lasts a few weeks. In the letting-go phase, the mother focuses on the forward movement of the family unit and incorporates the new baby into the family unit.
Thirty minutes after birth, the nurse assesses a client's fundus and lochia flow and notes an increased amount of lochia rubra and a few large clots. The client experienced a prolonged stage of labor before delivery. The uterine fundus remains midline an
d Rationale: Retained placental fragments cause uterine bleeding. The client may need to be sent to surgery for a dilation and curettage procedure to remove the placental fragments. If the fundus is firm, the amount of oxytocin in the I.V. fluids should be adequate. A prolonged second stage of labor or a primiparous status has no effect on uterine bleeding.
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?
A. Ma
b Rationale: The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. The client doesn't need to be seen or admitted for delivery. The client's signs aren't indicative of heart failure.
A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care?
A. Carefully titrating the o
c Rationale: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.
A client who is 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Of the following nursing diagnoses, the nurse should give the highest priority to:
A. R
a Rationale: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.
The uterus returns to the pelvic cavity in which time frame?
A. 7th to 9th day postpartum
B. 2 weeks postpartum
C. End of the 6th week postpartum
D. When the lochia changes to alba
a Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution.
A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer:
A. ritodrine (Yutopar).
B. bromocriptine (Parlodel).
C. magnesium sulfate.
D. betam
a Rationale: Ritodrine reduces frequency and intensity of uterine contractions by stimulating vitamin B12 receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia — a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).
client who is being admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority a
b Rationale: This question requires an understanding of station as part of the intrapartal assessment process. Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery.
A primigravida at 34 weeks' gestation is diagnosed with hydramnios. After delivery of the neonate, a priority for the nurse is to assess the neonate for:
A. diabetes mellitus.
B. esophageal atresia.
C. kidney disorders.
D. car
b Rationale: Esophageal fistula and anencephaly are associated with hydramnios, which is an excess of amniotic fluid. Oligohydramnios, or a decreased amount of amniotic fluid, is associated with renal defects. Diabetes mellitus and cardiac defects aren't associated with either oligohydramnios or hydramnios.
A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:
A. switch brands.
b Rationale: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.
As part of the respiratory assessment, the nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because:
A. neonates are obligate nose breathers.
B. nasal patency is required f
a Rationale: Neonates are obligate nose breathers and have no ability to breathe through their mouths. Therefore, blocked nares contribute to respiratory distress in the neonate. Nasal patency is unnecessary for neonate feeding. Nasal flaring may indicate respiratory distress. A deviated septum doesn't cause significant breathing difficulties.
When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to do which of the following?
A. Prevent seizures
B. Reduce blood pressure
C. Slow the process of labor
D. Incre
a Rationale: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.
When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation?
A. Cephalhematoma
B. Petechiae
C. Subdural hematoma
D. Caput succedaneum
d Rationale: Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture lines and typically clears within a few days after birth. Cephalhematoma is a swelling of the head that results from subcutaneous bleeding caused by pressure exerted on the soft tissues during delivery; it's characterized by sharply demarcated boundaries that don't cross the suture lines. Petechiae are minute, circumscribed, hemorrhagic areas of the skin. A subdural hematoma is an accumulation of blood between the dura and the brain tissue.
A client delivered a healthy full-term female neonate 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action?
A. Tachycardia and hypotension
B. Gush of vaginal blood when the client sta
a Rationale: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum client who has been sitting and may suddenly gush out when she stands up. A 2 blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. A client who has had a cesarean delivery usually feels pain at the incision site after her anesthesia has worn off.
The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
A. Presence of menses
B. Uterine enlargement
C. Breast sensitivity
D. Fetal heart tones
c Rationale: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.
Which of the following describes the term fetal position?
A. Relationship of the fetus's presenting part to the mother's pelvis
B. Fetal posture
C. Fetal head or breech at cervical os
D. Relationship of the fetal long axis to
a Rationale: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.
The nursery nurse is teaching a small-group teaching session to new parents in preparation for discharge. To comply with the law, the nurse instructs the parents that for the automobile trip home, the neonate should be in an approved car seat in the:
c Rationale: Neonates up to 20 pounds should be placed in an approved car seat in the back seat facing the back. This position provides the most protection for the baby in the event of an accident. Infants facing the front might be thrown forward in an accident. Infants in the front seat are at a greater risk for injury during an accident.
Which of the following should be the nurse's initial action immediately following the birth of the neonate?
A. Aspirating mucus from the neonate's nose and mouth
B. Drying the infant to stabilize the neonate's temperature
C. Promotin
b Rationale: The nurse's first action is to dry the neonate and stabilize the neonate's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried.
Which of the following is the primary reason for putting breast-feeding neonates to the breast immediately after delivery?
A. Neonates are hungry and need to eat.
B. Breast-feeding neonates immediately after birth establishes a learned resp
b Rationale: Immediately following birth, most neonates are quietly alert and are ready to nurse. Therefore, this is an ideal time to begin breast-feeding. Also, as one of the first postbirth experiences, the neonate is able to develop a learned response for feeding. The other answers are acceptable, but they don't consider the importance of developing responses as part of breast-feeding success.
Which of the following is not a contributory factor to thermoregulation in the preterm neonate?
A. Immature central nervous system (CNS)
B. Large skin surface area
C. Lack of subcutaneous (S.C.) and brown fat
D. Tendency towar
d Rationale: Tendency toward capillary fragility has nothing to do with thermoregulation. The hypothalamus is the site of temperature regulation. In preterm neonates, the CNS is poorly developed, so these neonates may be more prone to temperature instability. The large skin surface area provides the perfect medium for heat loss through evaporation and convection. Lack of S.C. and brown fat are also contributors to temperature instability. Without S.C. fat, there is nothing to insulate the infant from heat loss. Brown fat provides calories that help with heat production.
The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to:
A. assess th
a Rationale: Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.
A client with type 1 (insulin-dependent) diabetes mellitus who is a multigravida visits the clinic at 28 weeks' gestation. The nurse should instruct the client that for most pregnant women with insulin-dependent diabetes mellitus:
A. weekly fetal
d Rationale: For most clients with insulin-dependent diabetes mellitus, nonstress testing is done weekly until 32 weeks' gestation to assess fetal well-being. A nonreactive test may be followed by a contraction stress test (CST), but CST's aren't performed weekly because of the risks involved. The mother should make daily fetal movement counts beginning at 28 weeks' gestation. Labor may be induced for clients with large fetuses at 37 to 38 weeks' gestation.
A client, a gravida 3 para 2 at 35 weeks' gestation, comes in to the antepartum clinic for a check-up. She has been experiencing backaches after standing all day at her job as a grocery clerk. The nurse should suggest to the client that she practice an e
a Rationale: An exercise, such as the pelvic tilt, can help restore body alignment and alleviate backache. Squatting strengthens the pelvic muscles. Stretching and walking are good exercises but often don't relieve backache.
The nurse is reviewing discharge instructions with a client after an uncomplicated delivery. Which of the following symptoms is least important in characterizing postpartum "blues?"
A. Crying easily and feeling despondent
B. Loss
c Rationale: A variety of symptoms characterize postpartum blues, including loss of appetite, crying easily, despondency, difficulty sleeping and concentrating, feeling let down, and anxiety. Perceiving an altered body image is normal in pregnancy and the postpartum period because of the physiologic changes that take place at these times.
30-year-old primigravida tells the nurse that her hemorrhoids have become itchy and painful. After instructing the client about relief measures, the nurse determines that the client needs further instructions when she says:
A. "I should sit i
d Rationale: The client needs further instructions when she says she should decrease her fluid intake. Constipation further aggravates hemorrhoid pain and should be avoided through increased fluid and fiber intake. Warm sitz baths, topical ointments, and ice packs all can be helpful measures to reduce the pain, swelling, and itchiness.
The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
A. start using insulin.
B. start ta
d Rationale: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels.
A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's in
a Rationale: A full bladder will slow or stop cervical dilation and produce symptoms that could be misdiagnosed as arrest in labor. Other strategies, such as internal uterine monitoring, relaxation, and oxytocin augmentation, would be appropriate later, but assessing the bladder first is key.
Immediately after a spontaneous rupture of the membranes, the nurse observes a loop of umbilical cord protruding from the vagina. The first nursing action would be to:
A. administer oxygen.
B. notify the physician.
C. document the de
d Rationale: The first nursing action would be to elevate the hips on two pillows. The primary goal with prolapse of the umbilical cord is to remove the pressure from the cord. Changing the maternal position is the first intervention. Acceptable positions include knee-chest, side-lying, and elevation of the hips. The nurse may also perform a vaginal examination and attempt to push the presenting part of the cord while being careful not to add any pressure to the cord. Administering oxygen benefits the fetus only if circulation through the cord has been reestablished. The nurse does notify the physician and document the deceleration, care provided, and outcome but only after providing the initial emergency care to the client.
Which of the following hormones is responsible for the let-down reflex?
A. Oxytocin
B. Prolactin
C. Estrogen
D. Progesterone
a Rationale: Oxytocin is responsible for milk let-down, the process that brings milk to the nipple. The other hormones mentioned contribute indirectly to the lactation process. Prolactin stimulates lactation. Estrogen stimulates development of the duct in the breast. Progesterone acts to increase the lobes, lobules, and alveoli of the breasts.
A primigravida at 36 weeks' gestation tells the nurse that she has moderate breast tenderness. After providing the client with some suggestions for relief measures, the nurse determines that the client needs further instructions when she says:
b Rationale: The client needs further instructions when she says she should clean her nipples with soap. Soap can be extremely irritating to sensitive nipples. The client should wear a supportive bra at all times, change her sleeping position, and clean up the colostrum with water.
During the first 3 months, which hormone is responsible for maintaining pregnancy?
A. Human chorionic gonadotropin (HCG)
B. Progesterone
C. Estrogen
D. Relaxin
a Rationale: HCG is the hormone responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial HCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.
A client just had twins. Twin "A" weighs 2,500 g (5 lb, 8 oz), and Twin "B" weighs only 1,900 g (4 lb, 3 oz). In addition to routine nursing care, the physician has ordered that Twin "B" be kept in an Isolette to help mainta
c Rationale: The latest research indicates that cobedding twins does much to stabilize the neonates and promotes good adaptation to the extrauterine environment. Twins who are cobedded exhibit less crying and have better wake-sleep patterns than twins kept in separate cribs. Increasing the number of calories is unnecessary as is using a hot water bottle. Applying blankets for extra warmth is appropriate, but recent research acknowledges the greater advantage of cobedding.
The nurse observes a late deceleration. It's characterized by and indicates which of the following?
A. U-shaped deceleration occurring after the first half of the contraction, indicating uteroplacental insufficiency
B. U-shaped deceleration
a Rationale: A late deceleration is U-shaped and occurs after the first half of the contraction, indicating uteroplacental insufficiency. It's an ominous pattern and requires immediate action — such as administering oxygen, repositioning the mother, and increasing the I.V. infusion rate — to correct the problem. U- and V-shaped decelerations are variable decelerations occurring at unpredictable times during contractions and are related to umbilical cord compression. Deep U-shaped deceleration occurring before the contraction is early deceleration.
A female neonate delivered by elective cesarean birth to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of
b Rationale: The squeezing action of the contractions during labor enhances fetal lung maturity. Neonates who aren't subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.
An 18-year-old pregnant client tells the nurse she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize that she: <
d Rationale: The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly, but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily solve this situation.
A client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client under
c Rationale: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home; this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician.
A 20-year-old woman's pregnancy is confirmed at a clinic. She says her husband will be excited, but is concerned because she herself isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by:
A. referring her to co
b Rationale: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply, but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but he also needs to be reassured that these feelings are normal at this time.
The nurse is caring for a client who spontaneously aborted an 8-week-old fetus. The client is sobbing and moaning after the expulsion of the fetus. A priority goal for this client is that she'll:
A. verbalize her feelings related to the pregnancy
a Rationale: A pregnancy loss can precipitate the grieving process. Verbalizing her feelings about the pregnancy loss is important for the client so that she may recover from the grief process. Expressing decreased pain and increased comfort is important but not a priority at this time. Discussing the causes of the spontaneous abortion isn't helpful at this time. The client should avoid inserting anything into the vagina for at least 2 weeks.
Which condition could a mother have and still be allowed to breast-feed her child?
A. Positive for human immunodeficiency virus (HIV)
B. Active tuberculosis (TB)
C. Endometritis
D. Cardiac disease
c Rationale: Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from breast-feeding because of the strain on the mother's defective heart.
A client is being admitted to the labor unit. Because she's well advanced in labor, the nurse must prioritize the admission questions. Which information is most important to obtain when birth is imminent?
A. Duration of previous labor
B. Fr
d Rationale: Because birth is imminent, the most important information is the expected due date because it will help the health care team prepare to meet the special needs of a preterm or postterm infant. The duration of previous labor, frequency of contractions, and presence of bloody show aren't significant because birth is imminent and these factors don't affect the provision of safe care during childbirth.
The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones for which reason?
A. To determine fetal well-being
B. To assess for prolapsed cord
C. To assess fetal posit
b Rationale: After a client has an amniotomy, the nurse should ensure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.
Uterine atony, a condition in which the uterus is unable to maintain a state of firmness, is a common cause of hemorrhage in the postpartum period. In providing client care, the nurse is aware that uterine atony can result from:
A. hypertension. <
c Rationale: Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted so bleeding will be within normal limits. Cervical and vaginal tears can cause postpartum hemorrhage; however, in postpartum, a full bladder is the most common cause of uterine bleeding. Endometritis, an infection of the inner lining of the endometrium, and maternal hypertension don't cause postpartum hemorrhage.
Which of the following is the approximate time that the blastocyst spends traveling to the uterus for implantation?
A. 2 days
B. 7 days
C. 10 days
D. 14 weeks
b Rationale: The blastocyst takes approximately 1 week to travel to the uterus for implantation. The other options are incorrect.
Infertility in a 25-year-old couple is defined as which of the following?
A. The couple's inability to conceive after 6 months of unprotected attempts
B. The couple's inability to sustain a pregnancy
C. The couple's inability to conc
c Rationale: The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse.
Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems?
A. Decreased heart rate
B. Decreased cardiac output
C. Increased plasma
c Rationale: Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels.
Which of the following statements summarizes the underlying principle for the development of a parent-child relationship?
A. The parents-to-be had good role models in their childhood.
B. The relationship is part of the adult maturational pr
d Rationale: Early and frequent contact promotes love and satisfaction and can support the learned parental behavior that enhances parenting abilities and reduces ambivalence and feelings of resentment. Having good role models in childhood may be helpful but isn't the primary principle. Part of the adult maturational process excludes adolescents, who can form strong infant attachments. The relationship isn't directly related to the neonate's physical needs because human contact is needed for the infant to survive.
A client at 35 weeks' gestation complains of severe abdominal pain and passing clots. The client's vital signs are blood pressure 150/100 mm Hg, heart rate 95 beats/minute, respiratory rate 25 breaths/minute, and fetal heart tones 160 beats/minute. The a
b Rationale: The nurse must determine whether placenta previa or abruptio placenta is the problem. (Fifty percent of all clients with hypertension will develop abruptio placenta.) In this case, the presenting symptoms are highly suggestive of an abruption, so the nurse must determine the level of the uterus and mark that level on the client's abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because the placenta has detached early is rigid. A vaginal examination is contraindicated in the presence of bleeding. Bleeding from a placental previa is usually painless. Most nurses haven't been taught how to perform an ultrasound. If the client has a placental abruption, birth will most likely be by cesarean section.
When a client being seen in a fertility clinic doesn't respond to the clomiphene citrate, the physician prescribes I.M. menotropins (Pergonal). This drug increases her risk of producing multiple follicles that could mature to ovulation. To reduce the hig
a Rationale: The objective of menotropins therapy is to produce one or two healthy follicles; by carefully monitoring the client's ultrasound study results and serum estradiol levels, the nurse can determine the number of maturing follicles. Serum progesterone levels indicate whether ovulation has occurred and correlate well with basal body temperature changes but don't indicate the number of follicles. The test to detect urinary levels of LH is a hormonal assessment of ovulatory function — not an assessment of the number of maturing cells. Serum levels of HCG indicate whether the corpus luteum is producing enough estrogen and progesterone to maintain the pregnancy until the placenta develops further.
client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:
A. slow contractions.
B. enhance f
d Rationale: Betamethasone is given to promote fetal lung maturity by enhancing the production of surface-active lipoproteins. It has no effect on contractions, fetal growth, or infection.
Initial client assessment information includes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based
a Rationale: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia.
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of the following responses best indicates the normal neonate's breast-feeding behavior?
A. "Breast milk is ideal for your baby, so his
a Rationale: Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breast-feeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding infant.
The nurse is caring for a neonate 12 hours after birth. Which clinical manifestation would be the earliest indication that the neonate may have cystic fibrosis?
A. Steatorrhea
B. Meconium ileus
C. Decreased sodium levels
D. Rh
B Rationale: In cystic fibrosis, the small intestine becomes blocked with thick meconium; therefore, meconium ileus is the earliest indication that a neonate has the disorder. Steatorrhea may be present later and may be used as a guideline for administration of pancreatic enzymes. Infants and children with this disorder have increased sodium levels, and rhinorrhea isn't usually present.
A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response?
A. "I can see you're upset. Why don't we
B Rationale: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 12 months by an experienced health care provider. Discussing this situation at a later time and checking with the physician to give the client something to relax ignore the client's immediate concerns. Saying to wait until all tests are normal is vague and provides the client with little information.
During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurse's best action?
A. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and
A Rationale: Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary.
The nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her neonate. Whi
B Rationale: The behavior demonstrated by the mother is normal during the "taking-hold" process. The nurse should anticipate and support this behavior. Because this is normal behavior for establishing a relationship, it doesn't need to be reported. It's highly doubtful that the neonate would become chilled during this brief time of being undressed. Therefore, rewrapping the neonate and taking her back to the nursery to check her temperature isn't necessary.
When magnesium sulfate is administered to a client in labor, its action occurs at which of the following sites?
A. Neural-muscular junctions
B. Distal renal tubules
C. Central nervous system (CNS)
D. Myocardial fibers
A Rationale: Because magnesium has chemical properties similar to those of calcium, it will assume the role of calcium at the neural muscular junction. It doesn't act on the distal renal tubules, CNS, or myocardial fibers.
Which of the following describes a preterm neonate?
A. A neonate weighing less than 2,500 g (5 lb, 8 oz)
B. A low-birth-weight neonate
C. A neonate born at less than 37 weeks' gestation regardless of weight
D. A neonate diagno
C Rationale: A preterm infant is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Infants weighing less than 2,500 g are described as low-birth-weight neonate. A full-term neonate can be diagnosed with intrauterine growth retardation.
A client who is breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the client's breast engorgement?
d Rationale: Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant.
client is experiencing an early postpartum hemorrhage. Which action is inappropriate?
A. Inserting an indwelling urinary catheter
B. Fundal massage
C. Administration of oxytoxics
D. Pad count
D Rationale: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytoxics may be ordered to promote sustained uterine contraction.
Which of the following is normal neonate calorie intake?
A. 110 to 130 calories per kg
B. 30 to 40 calories per lb of body weight
C. At least 2 ml per feeding
D. 90 to 100 calories per kg
A Rationale: Calories per kg is the accepted way of determining appropriate nutritional intake for a neonate. The recommended calorie requirement is 110 to 130 calories per kg of neonate body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development.
Which assessment finding would the nurse interpret as abnormal for a term male neonate who is 1 hour old?
A. Enlargement of the mammary glands
B. Slightly yellowish hue to the skin
C. Blue hands and feet
D. Black and blue spot
B Rationale: A slightly yellowish hue to the skin would be abnormal because it's too early for the neonate to be showing signs of jaundice. The finding should be reported immediately to the neonate's health care provider. All of the remaining responses are normal findings for a 1-hour-old neonate male.
As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood
D Rationale: Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues." Postpartum depression is a psychiatric problem that occurs later in postpartum and is characterized by more severe symptoms of inadequacy. Because the client's behavior is normal, notifying her physician and conducting a home assessment aren't necessary.
A 35-year-old multigravida at 16 weeksÂ’ gestation tells the nurse that she has had frequent mood swings during this pregnancy. The nurse should suggest that the patient:
A. seek professional counseling.
B. keep her feelings to herself.
C Rationale: Mood swings are thought to be related to the altered hormonal levels associated with pregnancy. The nurse should suggest that the patient try to avoid fatigue and stress because these factors can exacerbate mood swings. The patient doesnÂ’t need professional counseling unless symptoms of psychosis are present. Telling the patient to keep her feelings to herself or to decrease her narcissistic behaviors would be inappropriate.
Breast engorgement occurs on the 2nd or 3rd postpartum day in both breast-feeding and non-breast-feeding mothers. Which of the following processes causes engorgement?
A. The body's natural response following delivery
B. Nuzzling of the neon
C Rationale: Engorgement isn't caused by milk in the breasts but by increased blood levels from vasodilation. The body's natural response after delivery, nuzzling by the neonate, and reduced estrogen levels contribute to milk production.
When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provides the most accurate picture of retention with overflow?
A. Frequent trips to the bathroom with an
C Rationale: Retention with overflow is a commonly missed nursing assessment. Because the client may be voiding and may not have an urge to void doesn't mean that bladder function has been properly restored. A varying urge to urinate with an average urine output of 100 ml is a classic picture of a client whose bladder is distended and needs to be catheterized to restore normal function.
Which assessment finding would lead the nurse to suspect dehydration in a preterm neonate?
A. Bulging fontanels
B. Excessive weight gain
C. Urine specific gravity below 1.012
D. Urine output below 1 ml/hour
D Rationale: A urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012.
When caring for a client who is having her second baby, the nurse can anticipate the client's labor will be which of the following?
A. Shorter than her first labor
B. About half as long as her first labor
C. About the same length of
B Rationale: A woman having her second baby can anticipate a labor about half as long as her first labor. The other options are incorrect.
The nurse palpates a multipara's fundus immediately after delivery of the placenta and assesses that it's boggy. The nurse massages the client's uterus until it's firm. Which medication would the nurse anticipate to administer if the uterus becomes boggy
A Rationale: Oxytocin would be given to cause the uterus to maintain a firm contraction. When the uterus remains boggy, the myometrium isn't contracted, and bleeding occurs at the placental attachment site. Ibuprofen has anti-inflammatory properties but doesn't prevent a boggy uterus. RhoGAM is given to prevent Rh isoimmunization. Magnesium sulfate is given to stop preterm labor contractions because it causes the uterine smooth muscle to relax.
A mother is concerned that her neonate son, who was delivered without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which instructions sh
B Rationale: Neonates who are born at term without complications have stores of brown fat located on the vital organs. These stores will provide the infant with the needed calories until lactation is well established. Cold, stress, and transitional neonate problems may use up the stores of brown fat. Telling the client not to worry and saying things will be fine ignores the mother's concerns. Starting the neonate on formula and notifying the physician are inappropriate at this time.
In performing a routine fundal assessment, the nurse finds a client's fundus to be "boggy." The nurse should first:
A. call the physician.
B. massage the fundus.
C. assess lochia flow.
D. start methylergonovine as or
B Rationale: The nurse should begin to massage the uterus so that the uterus will be stimulated to contract. Lochia flow can be assessed while the uterus is being massaged. The client shouldn't be left while the nurse calls the physician. If the fundus remains boggy and the uterus continues to bleed, the nurse should use the call light to ask another nurse to call the physician. An order for methylergonovine may be obtained at this time if needed, or the nurse may administer methylergonovine as written.
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse's interpretation is:
A. this is a normal adverse effect of phototherapy.
B. the neonate is developing lactose into
A Rationale: Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin is rising to dangerous levels.
A 19-year-old primagravida tells the nurse that the physician told her that she needed to increase her intake of thiamine (vitamin B1) in her diet. The nurse should instruct the client to consume more:
A. milk.
B. rice.
C. asparagus.
A Rationale: Good sources of thiamin include pork, liver, milk, potatoes, enriched cereals, and enriched breads. Rice, asparagus, and beef aren't good sources of thiamine.
After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs' test. What's the purpose of performing this test on a pregnant client?
A. To determine the fetal blood Rh factor
B. To determine the maternal
D Rationale: The indirect Coombs' test measures the level of antibodies against fetal Rh-positive factor in maternal blood. Although this test may determine the fetal blood Rh factor, the physician doesn't order it primarily for this purpose. The maternal blood Rh factor is determined before the indirect Coombs' test is done. No maternal antibodies against fetal Rh-negative factor exist.
A client with type 1 (insulin-dependent) diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide?
A. "Insulin requirements don't change
C Rationale: Maternal insulin requirements usually decrease during the first trimester due to rapid fetal growth and maternal metabolic changes, necessitating adjustment of the insulin dosage. Maternal insulin requirements fluctuate throughout pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish due to extreme maternal energy expenditure.
In the maternal attachment process, which of the following best describes the anticipated actions in the taking-hold phase?
A. Making sure the mother's needs are met first
B. Looking at the infant
C. Kissing, embracing, and caring fo
C Rationale: Taking-hold behaviors, the third step in parent-infant attachment, are best described by activities that involve tactile contact. These behaviors indicate that the parents have made significant strides toward taking care of their infant. Meeting the mother's needs first, looking at the infant, and talking about the infant are typically associated with the taking-in period.
For a client who is moving into the active phase of labor, the nurse should include which of the following as the priority of care?
A. Offer support by reviewing the short-pant form of breathing.
B. Administer narcotic analgesia.
A Rationale: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions and reduce the need for narcotics and other forms of pain relief, which can have an effect on fetal outcome. The nurse may administer narcotic analgesia and will observe for rupture of membranes but these don't take priority. In the active phase, the mother most likely is too uncomfortable to walk around the unit.
When assessing the fetal heart rate tracing, the nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if which of the following occurs?
A. The fetal heart rate remains at greater than 160 beats/minute
B Rationale: The normal parameter for the fetal heart rate is 120 to 160 beats/minute. Tachycardia is defined as a fetal heart rate greater than 160 beats/minute for more than 10 minutes. This definition takes into account the difference between tachycardia and acceleration.
client who is a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The client's cervical examination would reveal which of the following?
A. 2 cm dilated; 100% effaced at 0 station
B. 4 to 5 cm dilated
A Rationale: The nurse must distinguish between the primigravida and multigravida cervical dilation to make a plan of care for the laboring client. Primigravidas will efface and then dilate, while multigravidas will efface and dilate at the same time.
Which of the following clients would have the highest priority for being monitored with internal fetal monitoring?
A. Client with ruptured membranes
B. Client at complete dilation and +2 station
C. Client in latent phase with intact
D Rationale: The client with the fetus in a vertex position and meconium-stained fluid would have the highest priority for being monitored with internal fetal monitoring. The client with meconium-stained amniotic fluid is at highest risk for fetal distress. Internal fetal monitoring requires that the client have ruptured membranes and be dilated at least 1 cm and that the fetal presenting part is reachable. In many institutions, fetal monitoring is used routinely on all clients and is most useful in situations in which a high probability exists of maternal contractile problems or fetal distress. Fetal monitoring provides an almost continuous recording of the labor events. The client who is completely dilated and at +2 station is ready to deliver and wouldn't need fetal monitoring. Internal monitoring can't be done with intact membranes.
Which assessment would the nurse perform to validate that the membranes are ruptured?
A. Observe for a pink, mucus vaginal discharge.
B. Test the leaking fluid with nitrazine paper.
C. Assess the client's temperature, pulse, and bloo
B Rationale: The nitrazine test determines whether the client's membranes have ruptured. The nurse performs a sterile vaginal examination, inserts the nitrazine test tape, then assesses the tape for a color change. If the membranes are ruptured, the tape becomes bluish, which indicates that the vaginal environment is alkaline. If the test tape remains yellow or green, the vaginal environment is acidic, indicating that the membranes aren't ruptured. False-positive results may be obtained if a large amount of bloody show or vaginal bleeding is present, if previous vaginal examinations have been done using sterile lubricant, or if the tape is touched by the nurse's fingers. Microscopic examination (fern test) can also validate rupture of the membranes. Observing for pink mucus discharge; assessing temperature, pulse, and blood pressure; and culturing a urine specimen don't validate rupture of the membranes.
woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:
A. recognize these as normal early pregnancy signs and symptoms.
B. question her further about these signs and sym
A Rationale: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.
When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding succes
B Rationale: Breast reduction surgeries are currently done in a way that protects the milk sacs and ducts, so breast-feeding after surgery is possible. Still, it's good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother's ability to meet all of her baby's nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client's psychological adaptation to mothering may be dependent on how successfully she breast-feeds.
During a discussion with health care workers, the nurse correctly describes the action of subdermal contraceptive implants (Norplant system) as the following:
A. High estrogen and progesterone levels contained within the implants make ovulation im
B Rationale: Subdermal contraceptive implants contain progestin only and are believed to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and creating a thin, atrophic endometrium. The implants don't contain nonoxynol 9, which is a spermicide.
An appropriate-for-gestational-age neonate should weigh:
A. between the 10th and the 90th percentiles for age.
B. at least 2,500 g (5 lb, 8 oz).
C. between 2,000 and 4,000 g (4 lb, 6 oz and 8 lb, 12 oz).
D. in the 50th percent
A Rationale: Appropriate-for-gestational-age neonate weights fall between the 10th and the 90th percentiles for age. Large-for-gestational-age weight is above the 90th percentile, and small-for-gestational-age is below the 10th percentile for age.
When caring for a client with preeclampsia, which action is a priority?
A. Monitoring the client's labor carefully and preparing for a fast delivery
B. Continually assessing the fetal tracing for signs of fetal distress
C. Checking v
D Rationale: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority.
When does the third stage of labor end?
A. When the neonate is born
B. When the client is fully dilated
C. After the birth of the placenta
D. When the client is transferred to her postpartum bed
C Rationale: The third stage of labor ends with the birth of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor comprises the first 4 hours after birth.
A neonate girl is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the infant under the radiant hea
B Rationale: Maintenance of a blood sugar level at 50 mg or greater is required to ensure enough glucose for the brain and metabolism. Neonates who are cold stressed are at high risk for low blood sugars, a condition that requires immediate intervention to prevent damage to the neurologic system. Performing a full assessment, reviewing the pregnancy and delivery history, and contacting the pediatrician are done after the blood glucose level is obtained.
The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her baby?
A. Encourage breast-feeding so that she c
D Rationale: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.
At what gestational age would a primigravida expect to feel "quickening"?
A. 12 weeks
B. 16 to 18 weeks
C. 20 to 22 weeks
D. By the end of the 26th week
C Rationale: It's important for the nurse to distinguish between a client who is having her first baby and one who has already had a baby. For the client who is pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations.
Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?
A. Breech position
B. Late decelerations <
A Rationale: Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
A. Poor clotting mechanism
B. High h
D Rationale: The primary cause of neonate jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it.
Which of the following is not a contributing factor to unstable blood sugars in the neonate?
A. Prematurity
B. Respiratory distress
C. Postdated infant
D. Cesarean delivery
D Rationale: Neonates delivered by cesarean birth without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. Stores of brown fat aren't deposited until 36 weeks, so infants born at less than 36 weeks won't have the necessary stores to maintain a normal blood glucose level. Neonates who have respiratory distress or are postdated will use up their stores of brown fat as a result of these complications.
The nurse is caring for a 15-year-old primigravida who visits the clinic for the first time at 20 weeks' gestation. A priority goal for this client is that she'll be able to:
A. maintain a steady weight gain until term.
B. record the number
C Rationale: The purpose of prenatal care is to detect signs and symptoms of complications early so that treatment can begin and fetal outcome will be good. This adolescent client visits the clinic at 20 weeks' gestation; therefore, a priority goal is that the client attend prenatal appointments on a regular basis. Maintaining a steady weight gain isn't a priority goal unless there's some indication that the client hasn't been maintaining a steady and appropriate weight gain. Recording the number of fetal movements four times daily isn't indicated, and explaining the process of fetal development isn't a priority at 20 weeks' gestation.
A client is admitted for an amniocentesis. Initial assessment findings include the following: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 g/dl, hematocrit 35%, and type O-negative blood. Which action would be most important to in
A Rationale: To prevent maternal sensitization, RhoGAM must be given after any invasive procedure on an Rh-negative client. All the other aspects are important but the administration of RhoGAM is the priority.
To ensure that the breast-feeding neonate's weight loss remains within the expected parameter of 5% to 10%, the nurse should initially establish which type of feeding schedule?
A. Maintain the neonate on an every-2-hours feeding schedule.
D Rationale: Breast-feeding schedules should respond to the demands of the neonate, at a minimum of every 4 hours. An infant may not be hungry or willing to eat every 2 hours. Every 4 hours may be too long for the neonate. Using supplementary bottles may interfere with the mother's milk production and cause nipple confusion.
A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver?
A. Breast tenderness
B. Breakthrough bleedi
D Rationale: Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the health care provider. Because these two effects in particular may be precursors to cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.
A nurse in a prenatal clinic is assessing a 28-year-old woman who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia?
A. Glycosuria, hypertension, seizures
B. Hematuria, blurry vision
D Rationale: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Seizures are a sign of eclampsia. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. The other findings aren't typically found in women with preeclampsia.
The nurse assessing the homeostatic status of a postpartum woman should recognize which of the following statements as correct?
A. A slow trickle of blood from the vagina can cause as much harm as a greater outpouring.
B. Hematomas in the v
A Rationale: A slow trickle of blood from the vagina can cause as much harm as a greater outpouring. Blood can pool under the client's buttocks. It's important for the nurse to assess blood loss on the perineal pad and under the buttocks. Hematomas can be treated with ice packs; however, according to the size of the hematoma, surgical intervention may be required. Rupture of a hematoma can cause significant blood loss. A fundus that remains boggy is always a threat to the client's safety. The fundus should remain firm and well contracted. Because of hypervolemia in pregnancy, most women can lose up to 500 ml blood from a vaginal delivery without complications.
The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary?
A. Increased maternal blood pressure of 150/90 mm Hg
B. Decreased amount
C Rationale: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean delivery to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.
Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client?
A. Provide her with
A Rationale: Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs.
An intrapartum client asks the nurse, "Why can't I have anything to eat during labor?" Which of the following statements would the nurse include in her response?
A. "You don't need food during labor because you have an I.V. infusion
B Rationale: The nurse would tell the client that the GI system stops during labor. Gastric motility and absorption of food are decreased during labor. Gastric emptying time is prolonged, and the food remains in the stomach regardless of when it was eaten. Some narcotics also slow gastric emptying time and increase the risk of aspiration should general anesthesia be needed. Light foods taken during labor haven't been found to slow the contractile pattern.
A healthy term white neonate male should weigh approximately:
A. 7 lb (3.2 kg).
B. 8 lb (3.6 kg).
C. 7½ lb (3.4 kg).
D. an amount that varies with length of pregnancy
C Rationale: The normal weight for a term neonate white male should be about 7½ lb. White females should weigh about 7 lb. Neonates of Asian or Black mothers often weigh less.
A multigravida at 37 weeks' gestation is scheduled to undergo amniocentesis. The nurse determines that she needs further explanation when the client says:
A. "About 2 tsp of amniotic fluid will be removed."
B. "A sonogram wil
A Rationale: The client needs further instructions when she says about 2 tsp will be removed. Refined analysis requires 15 to 20 ml of amniotic fluid. A sonogram is used in amniocentesis, and pressure may be felt when the needle is inserted. The client should have a full bladder before the procedure.
A client is a gravida 1 para 1001 who has vaginally delivered a full-term infant without complications. After the first postpartum day, she tells the postpartum nurse that she's afraid something is wrong because she's perspiring and urinating more than n
C Rationale: It's common for a woman to experience diuresis and diaphoresis after giving birth. The body loses the excess fluid that accumulated during pregnancy. Also common is an elevated temperature (up to 100.4° F [38° C]) that can be attributed to dehydration. During labor, the client isn't allowed anything by mouth, which can lead to dehydration. Offering to report the symptoms or temperature to the physician or suggesting that the client is exhibiting signs of diabetes isn't appropriate.

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