Ch 27 Test 1 Flashcards
A woman who is 38 weeks’ pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
a. Lightening
b. Braxton-Hicks contractions
c. Initiation of labor
d. Engagement
ANS: A
The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally.
How do Braxton-Hicks contractions differ from labor contractions?
a. Last several minutes.
b. Are always regular.
c. Do not dilate the cervix.
d. Are only mild.
ANS: C
Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can range from mild to moderate in severity, and increase in duration as the pregnancy progresses.
The nurse is trying to differentiate true labor from false labor. Which of the following is correct regarding true labor?
a. Discomfort of the contraction is in the fundus.
b. Contractions do not follow a pattern.
c. Contractions get stronger with ambulation.
d. Contractions may stop with ambulation.
ANS: C
Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions.
Why is the size and shape of the true pelvis more important than that of the false pelvis?
a. The fetal head must be able to pass through the true pelvis.
b. The true pelvis are the mother’s measurements.
c. The size of the false pelvis can change.
d. The size of the true pelvis needs to be larger.
ANS: A
The size and shape of the true pelvis is more important than the false pelvis because the fetal head must be able to pass through for vaginal delivery to occur.
What method is used to visualize soft tissue and to determine adequacy of the pelvis with no detrimental effects to the fetus?
a. Pelvimetry
b. Palpation
c. Ultrasonography
d. X-ray
ANS: C
In more than 20 years of use, ultrasonography has had no detrimental effects on the fetus. Pelvimetry and x-ray uses radiation to visualize bony prominences. Pelvimetry is not used in the pregnant patient due to detrimental effects to the fetus. Palpation does not allow for visualization of soft tissue.
What area of the uterus provides the force during a contraction?
a. Lower portion
b. Middle portion
c. Upper portion
d. Cervical portion
ANS: C
The upper portion of the uterus provides the force during contractions.
What is the largest diameter of the fetal skull?
a. Temporal
b. Biparietal
c. Lateral
d. Frontal-occipital
ANS: B
The largest transverse diameter of the fetal skull is the biparietal measurement. If this is too large, the skull may not be able to enter the mother’s pelvis.
A nurse is teaching a group of primigravidas that during delivery, pressure on the fetal skull may produce changes in the shape of the skull. What is the reshaping of the skull called?
a. Pressure response
b. Overlapping
c. Molding
d. Spacing
ANS: C
The reshaping of the skull bones in response to pressure is called molding.
What is the ideal attitude for the fetal body during labor?
a. Extension
b. Lateral
c. Flexion
d. Transverse
ANS: C
The ideal attitude for the fetal body is flexion.
Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus. How should the nurse document the fetal position?
a. Right occiput anterior (ROA), vertex
b. Left occiput anterior (LOA), vertex
c. Right occiput transverse (ROT), breech
d. Left occiput anterior (LOA), breech
ANS: A
Fetal position can be determined by the Leopold maneuver, which defines the relationship of the presenting part to the maternal pelvis quadrant. A soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus indicate a right occiput anterior (ROA), vertex positioning.
During the second stage of labor, how often should the nurse should monitor the fetal heart rate?
a. Every 5 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every hour
ANS: A
Fetal heart rate should be assessed every 5 minutes during the second stage of labor.
Which type of monitor will assesses the intensity of contractions?
a. External monitor
b. Fetal monitor
c. Maternal monitor
d. Internal monitor
ANS: D
Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity.
When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
a. Early deceleration due to head compression
b. That the fetus is in acute distress
c. Variable decelerations due to cord compression
d. That these are late decelerations
ANS: A
This indicates early decelerations because of head compression.
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
a. Cool fluids to drink
b. A backrub in the sacral area
c. Assisting to lie in a supine position
d. Decreasing illumination in the room
ANS: B
Backache in the sacral area is a common complaint during the first stage of labor. The keyword is “comfort” in the question. Providing a backrub is providing comfort to the laboring patient.
A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment?
a. Position patient on her left side.
b. Start oxygen per nasal cannula.
c. Reassure the mother the rate is normal.
d. Notify the health care provider at once.
ANS: C
The normal FHR is 120 to 160 beats/min. No interventions are required.
The patient’s membranes have just ruptured. What is the first priority of the nurse?
a. Turn the patient on the left side.
b. Perform a Nitrazine test.
c. Check the fetal heart rate (FHR).
d. Perform a vaginal examination.
ANS: C
The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby.
A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
a. There is no dilation.
b. The contractions are in the fundus.
c. The cervix has softened and effaced.
d. The contractions are irregular.
ANS: C
One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic.
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take?
a. Monitor intensity of contractions.
b. Place the patient in the knee-chest position.
c. Notify the charge nurse.
d. Ask the patient to perform a Valsalva’s maneuver.
ANS: B
The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse will need to be notified, and the contractions will need to be monitored. However, the priority is reducing the pressure on the prolapsed cord.
A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
a. Correctly identifying abnormal FHR patterns and prescribing medication
b. Correctly identifying abnormal FHR patterns and notifying the health care
provider
c. The nurse is not legally responsible for fetal monitoring
d. Providing technical assessment to the monitor technicians
ANS: B
Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order.
A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when?
a. The cervix is completely effaced.
b. The baby is in position.
c. The cervix is fully dilated.
d. The woman begins pushing.
ANS: C
The first stage of labor begins with regular contractions and ends with complete dilation of the cervix.
The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment, which assessment is the priority?
a. The number of previous pregnancies
b. When the baby is due
c. When the patient last ate
d. The timing of contractions
ANS: D
Assessment begins with timing the contractions on admission to form a database.
During labor, the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
a. Ask the husband to leave the room.
b. Assure the husband that such behavior is normal.
c. Remind the patient that the husband wants to help.
d. Change the patient’s position.
ANS: B
During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal.
A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. Which statement is true?
a. The narrowest diameter of the presenting part has reached the pelvic outlet.
b. The descending part is being initiated through the midpelvis.
c. The widest diameter of the presenting part crosses the pelvic inlet.
d. The narrowest diameter of the presenting part is at the ischial spines.
ANS: C
Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet.
The health care provider has decided to induce labor with prostaglandin gel and an amniotomy. When should the nurse expect that labor will start?
a. 1 hour
b. 4 hours
c. 8 hours
d. 12 hours
ANS: A
Medically approved methods of inducing labor include prostaglandin gel application that usually induces labor in 1 hour or less.
A mother has entered the second stage of labor. When does the second stage of labor end?
a. When the mother begins to push
b. When the baby’s head crowns
c. With delivery of the baby
d. With delivery of the placenta
ANS: C
The second stage of labor begins with complete dilation and ends with the birth of the baby.
Why is oxytocin administered in the third stage of labor?
a. To stimulate lactation
b. To relieve postpartum pain
c. To stimulate uterine contractions
d. To sedate the mother so she can rest
ANS: C
Oxytocin makes the uterus contract and reduces postpartum hemorrhage.
After the delivery of a newborn, what is the priority action of the nurse?
a. Place the newborn on the right side.
b. Cover the cord stump.
c. Dry the infant immediately.
d. Suction nose and mouth.
ANS: D
To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent hypothermia.
An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar score should be assigned to this infant?
a. 5
b. 7
c. 8
d. 10
ANS: C
The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2; pink body, blue limbs = 1.
For the first hour following delivery, how often should the nurse assess the mother?
a. Every 5 minutes
b. Every 10 minutes
c. Every 15 minutes
d. Every 30 minutes
ANS: C
During the first hour, assessments are done every 15 minutes.
When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured, the paper turns yellow. What does this finding indicate?
a. Acidic discharge, membranes intact
b. Acidic discharge, membranes have ruptured
c. Neutral, not enough discharge to measure
d. Alkaline, membranes have ruptured
ANS: A
When the Nitrazine paper turns yellow it is indicative of acidic discharge, meaning the membranes are intact. Amniotic fluid is alkaline and turns the paper blue.
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Which assessment findings suggest probable fetal distress? (Select all that apply.)
a. Fetal heart rate (FHR) of 120
b. Meconium-stained amniotic fluid
c. Decreased FHR during contractions
d. Strong contractions 10 seconds apart
e. Slow return of FHR to baseline
ANS: B, E
Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are indicative of fetal distress. All other options are normal.
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A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center? (Select all thatapply.)
a. The patient is a primigravida.
b. The patient will be having a planned cesarean delivery.
c. The mother has preeclampsia.
d. The baby is a boy.
e. The mother has no support system.
ANS: B, C
Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mother’s support system would not be factors considered when determining risk for delivering in a birthing center.
