FINAL ch 13, 16, 21 Flashcards

Question

Which complication is associated with a prolonged second stage of labor? A. Umbilical cord prolapse B. Preeclampsia C. Third- and fourth-degree perineal lacerations D. Amniotic fluid embolism

Answer 1

C. Third- and fourth-degree perineal lacerations Rationale: Prolonged second stage of labor increases the risk of maternal complications such as perineal lacerations, puerperal infections, and postpartum hemorrhage.

Answer 2

A. Encourage the patient to continue pushing during contractions Rationale: During the second stage, the mother often feels in control and focused on pushing. The nurse should provide encouragement and guidance to support effective pushing efforts during contractions.

Answer 3

D. Facilitate the fetus’s movement through the birth canal Rationale: The cardinal movements of labor are a series of positional changes that the fetus undergoes to navigate the birth canal and facilitate delivery.

Answer 4

D. Pressure felt in the pelvic floor and rectum Rationale: Pressure in the pelvic floor and rectum indicates fetal descent through the birth canal, stimulating stretch receptors and contributing to the maternal urge to push.

Answer 5

B. The top of the fetal head remains visible between contractions. Rationale: Crowning occurs when the top of the fetal head no longer regresses between contractions and remains visible at the vaginal opening.

Answer 6

C. Rectal pressure and an overwhelming urge to push Rationale: During active pushing, the laboring mother feels rectal pressure caused by the fetal presenting part and experiences a physiological urge to push.

Answer 7

A. It dulls the sensation to push. Rationale: An epidural can dull the physiological urge to push, making the pushing phase less intense for the laboring mother.

Answer 8

B. Up to 2 hours Rationale: In multiparous women, the second stage of labor typically lasts up to 2 hours. In first labors, it may last up to 3 hours.

Answer 9

A. Perineum bulging and increased bloody show Rationale: The bulging of the perineum and an increase in bloody show indicate that the fetus is descending and labor is progressing during the second stage.

Answer 10

C. Late second stage Rationale: In the late second stage of labor, the fetal head becomes visible but may still regress between contractions until crowning occurs.

Answer 11

B. Labor progresses slower than previously thought, requiring more time for vaginal delivery. Rationale: Current evidence shows that labor progresses more slowly than previously believed, and many women may need additional time to achieve vaginal delivery without moving to surgical interventions.

Answer 12

D. It minimizes the risk of pelvic floor damage. Rationale: Spontaneous pushing reduces pelvic floor damage by avoiding the prolonged Valsalva maneuver, which is associated with more strain and injury.

Answer 13

C. Reduces fetal oxygenation and causes hemodynamic changes Rationale: Directed pushing, especially prolonged Valsalva bearing-down, can lead to hemodynamic changes in the mother and interfere with fetal oxygen exchange.

Answer 14

A. Encouraging women to follow their spontaneous urge to push Rationale: The WHO recommends encouraging women to follow their own urge to push rather than using directed pushing.

Answer 15

A. Using open-glottis pushing with grunting and vocalization Rationale: A physiologic, woman-directed approach involves open-glottis pushing, allowing the mother to bear down naturally with involuntary efforts.

Answer 16

D. Reduces maternal fatigue and improves fetal oxygenation Rationale: Delaying pushing conserves maternal energy and allows for better oxygenation of the fetus, optimizing outcomes for both mother and baby.

Answer 17

B. Passive fetal descent without maternal pushing Rationale: Laboring down involves allowing passive fetal descent with minimal or no maternal pushing, particularly in women with epidurals.

Answer 18

C. Increased pelvic floor damage Rationale: Prolonged directed pushing increases the risk of pelvic floor damage and adverse maternal outcomes.

Answer 19

A. Encouraging laboring down Rationale: Laboring down allows for passive fetal descent, conserving maternal energy and improving overall outcomes.

Answer 20

B. Encouraging the mother to use her own pushing techniques Rationale: Evidence-based management supports the mother’s spontaneous patterns and techniques of pushing in response to her sensations.

Answer 21

C. Expiratory grunting with involuntary bearing down Rationale: Open-glottis pushing involves natural expiratory grunting and involuntary bearing down, which aligns with the body’s physiological processes.

Answer 22

D. Evidence suggesting improved maternal energy and fetal oxygenation Rationale: Delaying pushing optimizes maternal energy and enhances fetal oxygenation without increasing adverse outcomes.

Answer 23

B. Spontaneous variations in strength and duration of pushing Rationale: Effective second-stage management involves the mother using her own natural patterns, including variations in strength and duration of pushing.

Answer 24

B. Supporting the mother’s spontaneous urge and position changes Rationale: Evidence-based care during the second stage prioritizes supporting the mother’s natural instincts and encouraging position changes to enhance comfort and labor progress.

Answer 25

D. Administering a uterotonic agent as ordered Rationale: Administering a uterotonic agent is critical to preventing postpartum hemorrhage, the leading cause of maternal mortality during the third stage of labor.

Answer 26

A. A sudden gush of blood and lengthening of the umbilical cord Rationale: Placental separation is typically signaled by a gush of blood, lengthening of the umbilical cord, and changes in the uterine shape.

Answer 27

D. Facilitates the newborn’s transition to extrauterine life Rationale: Skin-to-skin contact promotes thermoregulation, bonding, and adaptation of the newborn to extrauterine life.

Answer 28

B. Administering a uterotonic agent and performing controlled cord traction Rationale: Active management involves administering a uterotonic, controlled cord traction, and uterine fundal massage after placental expulsion to prevent postpartum hemorrhage.

Answer 29

D. Postpartum hemorrhage Rationale: Postpartum hemorrhage is the most common complication during the third stage of labor and can be life-threatening without prompt intervention.

Answer 30

B. The placenta is delivered naturally without controlled cord traction. Rationale: Expectant management allows the placenta to deliver naturally without interventions such as controlled cord traction or uterotonic administration.

Answer 31

C. Perform vigorous uterine fundal massage Rationale: Uterine fundal massage stimulates contraction of the uterus and is a critical initial intervention to control bleeding and prevent uterine atony.

Answer 32

C. The uterus changes its shape to globular. Rationale: A globular-shaped uterus, along with upward rising of the uterus, cord lengthening, and a sudden trickle of blood, are all signs that the placenta has separated from the uterine wall and is ready to deliver.

Answer 33

D. The shiny, gray fetal side presents first. Rationale: In the Schultz mechanism, the fetal side (shiny gray) of the placenta delivers first, while the Duncan mechanism involves the maternal side (red raw) delivering first.

Answer 34

A. Monitoring for signs of incomplete placental separation. Rationale: It is critical to monitor for signs of incomplete placental separation to prevent complications such as hemorrhage or retained placenta.

Answer 35

D. Duncan mechanism. Rationale: The maternal side (red and raw) of the placenta presenting first is termed the Duncan mechanism, while the fetal side (shiny and gray) is the Schultz mechanism.

Answer 36

A. Continuous uterine contractions and retraction. Rationale: After the infant is born, strong uterine contractions and retraction decrease the uterine size, pulling the placenta away from the uterine wall.

Answer 37

B. To promote uterine contraction and prevent hemorrhage. Rationale: Uterine massage is performed to help the uterus contract, which constricts blood vessels and reduces the risk of postpartum hemorrhage.

Answer 38

A. 500 mL Rationale: Normal blood loss during a vaginal birth is typically around 500 mL, with up to 1,000 mL considered normal for a cesarean birth.

Answer 39

B. Postpartum hemorrhage. Rationale: Retained placental tissue can interfere with uterine contractions, leading to postpartum hemorrhage due to failure of the uterus to contract fully.

Answer 40

A. Only when the placenta fails to separate. Rationale: External traction is used only if the placenta fails to separate spontaneously, assisting with its expulsion in a timely manner.

Answer 41

D. 1,000 mL Rationale: Severe blood loss is defined as greater than 1,000 mL following vaginal birth, which increases the risk of complications such as hypovolemic shock.

Answer 42

C. Within 2 to 30 minutes Rationale: The placenta is typically expelled within 2 to 30 minutes following birth, depending on whether external traction is used or the placenta delivers spontaneously.

Answer 43

A. Manual extraction by the healthcare provider. Rationale: If the placenta does not expel within the normal time frame, manual extraction by the healthcare provider is necessary to prevent complications such as hemorrhage.

Answer 44

C. Massage the fundus to encourage firm contraction. Rationale: If the uterus becomes boggy (soft), the nurse should massage the fundus to encourage uterine contraction, which helps prevent postpartum hemorrhage.

Answer 45

C. A soft, non-contracted fundus. Rationale: A boggy uterus, which is soft and not well-contracted, is a sign of uterine atony, a risk factor for postpartum hemorrhage.

Answer 46

B. To monitor for complications such as hemorrhage, bladder distention, and venous thrombosis. Rationale: The primary focus during the fourth stage is to monitor the mother closely for complications, including hemorrhage, bladder distention, and venous thrombosis.

Answer 47

B. At the level of the umbilicus. Rationale: In the first hour after birth, the fundus typically rises to the level of the umbilicus, and its position is monitored for signs of uterine atony.

Answer 48

C. Cramp-like discomfort. Rationale: Cramp-like discomfort is common during the fourth stage of labor as the uterus contracts to its pre-pregnancy size.

Answer 49

B. Red in color, mixed with small clots, and of moderate flow. Rationale: Lochia during the fourth stage is typically red, mixed with small clots, and has moderate flow as the body expels the remaining blood and tissue from the uterus.

Answer 50

D. Blood pressure, heart rate, and fundus status. Rationale: Vital signs, including blood pressure, heart rate, and fundus status, should be monitored every 15 minutes during the first hour after birth to assess for complications.

Answer 51

C. Due to the physical exertion of labor and delivery. Rationale: The woman may feel hungry and thirsty after the physical exertion of labor and delivery, as the body requires energy to recover and stabilize after birth.

Answer 52

B. Decrease in progesterone levels. Rationale: The onset of labor is associated with a decrease in progesterone levels and an increase in estrogen and prostaglandins, which stimulate uterine contractions.

Answer 53

D. Significant cervical change. Rationale: The most reliable sign of active labor is significant cervical change, which indicates that labor is progressing toward full dilation.

Answer 54

B. To begin the process of pushing to deliver the baby. Rationale: The second stage of labor focuses on pushing and moving the fetus through the birth canal until the baby is born.

Answer 55

A. Expulsion of the placenta. Rationale: The third stage of labor focuses on the expulsion of the placenta, ensuring it is fully delivered and the uterus contracts properly to minimize bleeding.

Answer 56

D. Monitor for postpartum hemorrhage. Rationale: The priority action during the fourth stage is to monitor for postpartum hemorrhage, ensuring the uterus remains firm and contractions are effective in reducing bleeding.

Answer 57

B. Second stage. Rationale: The second stage of labor begins at full dilation and ends with the birth of the infant. This stage involves pushing and the descent of the fetus through the birth canal.

Answer 58

D. 8 Rationale: A Bishop score of over 8 indicates a high likelihood of a successful vaginal birth without the need for cervical ripening methods.

Answer 59

C. Use of cervical ripening methods. Rationale: A Bishop score less than 6 generally indicates the need for cervical ripening methods before induction of labor to improve the chances of a successful vaginal birth.

Answer 60

C. Pelvic rest. Rationale: Pelvic rest is not a component of medical induction of labor. The two primary components are cervical ripening and induction of contractions, with cervical readiness evaluated through a Bishop score.

Answer 61

B. 5 Rationale: The patient's Bishop score is calculated as follows: - Dilation (1–2 cm): 1 point - Effacement (40–50%): 1 point - Station (-2): 1 point - Cervical consistency (Medium): 1 point - Position of cervix (Midposition): 1 point Total = 5 points.

Answer 62

B. Cervix is unfavorable for induction Rationale: A Bishop score less than 6 indicates an unfavorable cervix, suggesting that cervical ripening interventions may be necessary before induction of labor.

Answer 63

D. Station Rationale: Station refers to the position of the presenting part of the fetus (e.g., head) relative to the ischial spines of the pelvis. It ranges from -3 (high in the pelvis) to +2 (near delivery).

Answer 64

A. Increased likelihood of successful induction B. Cervix is ripened D. Patient is ready for labor induction Rationale: A score of 8 or higher indicates the cervix is favorable for induction, with a high chance of a successful vaginal delivery.

Answer 65

C. Administering cervical ripening agents Rationale: A Bishop score of 4 indicates an unfavorable cervix. Cervical ripening agents, such as prostaglandins, are typically used to soften and prepare the cervix for induction.

Answer 66

D. +1 Rationale: A station of +1 or +2 is assigned 2 points on the Bishop scoring system, indicating that the presenting part is low in the pelvis.

Answer 67

C. 11 Rationale: The patient's Bishop score is calculated as follows: - Dilation (3–4 cm): 2 points - Effacement (80%): 3 points - Station (+1): 2 points - Cervical consistency (Soft): 2 points - Position of cervix (Anterior): 2 points Total = 11 points.

Answer 68

A. Dilation: Closed, Effacement: 0–30%, Station: -3, Cervical Consistency: Firm, Position of Cervix: Posterior Rationale: These findings (closed dilation, 0–30% effacement, -3 station, firm cervix, and posterior position) result in the lowest possible Bishop score of 0.

Answer 69

D. Very soft Rationale: A "Very soft" cervix is assigned the highest score (3 points) for cervical consistency in the Bishop scoring system.

Answer 70

D. 3 Rationale: A dilation of 5–6 cm scores 3 points in the Bishop scoring system.

Answer 71

C. 6 Rationale: A Bishop score of at least 6 is generally considered favorable for labor induction in nulliparous patients.

Answer 72

C. 2 Rationale: An anterior cervix scores 2 points in the Bishop scoring system.

Answer 73

D. 80% Rationale: An effacement of 80% scores the maximum of 3 points for this parameter in the Bishop scoring system.

Answer 74

B. The cervix is ripened and favorable for induction Rationale: A score of 9 indicates a highly favorable cervix, with a high likelihood of successful labor induction.

Answer 75

A. Cervical dilation C. Effacement D. Station E. Position of cervix Rationale: The Bishop scoring system evaluates cervical dilation, effacement, station, cervical consistency, and position of the cervix to assess readiness for labor induction. Fetal heart rate is not included.

Answer 76

C. Shortened, softened, and anterior. Rationale: A ripe cervix is described as shortened, softened, and anterior. These changes increase the likelihood of successful labor induction and vaginal birth.

Answer 77

A. The need for cervical ripening before induction of labor. Rationale: A Bishop score of less than 6 suggests the cervix is unfavorable and indicates the need for cervical ripening before labor induction to increase the chances of a successful vaginal delivery.

Answer 78

B. To allow for collagen breakdown, softening, and elasticity of the cervix. Rationale: Cervical ripening involves the breakdown of collagen, leading to cervical softening, elasticity, and distensibility, which are necessary for cervical dilation and effacement.

Answer 79

C. Continuous fetal monitoring. Rationale: Continuous fetal monitoring is used during labor but is not a method for cervical ripening. Mechanical and pharmacologic methods, as well as membrane sweeping, are commonly used for this purpose.

Answer 80

C. A successful vaginal birth is likely. Rationale: A Bishop score of 8 or higher indicates a ripe cervix, suggesting a high likelihood of a successful vaginal birth without additional cervical ripening methods.

Answer 81

D. To apply continuous pressure to the cervix to stimulate effacement and dilation. Rationale: Mechanical methods, such as the insertion of a Foley catheter, apply continuous pressure to the cervix to promote effacement and dilation.

Answer 82

B. Increased estrogen and prostaglandins. Rationale: Cervical ripening is facilitated by hormonal changes, including increased levels of estrogen and prostaglandins, which lead to collagen breakdown and softening of the cervix.

Answer 83

C. Administering a cervical ripening agent. Rationale: A Bishop score of less than 6 indicates that the cervix is unripe, and cervical ripening agents should be used before initiating labor induction to improve the chances of a successful vaginal birth.

Answer 84

C. Nonpharmacologic methods for cervical ripening lack scientific validation for safety and efficacy. Rationale: Nonpharmacologic methods such as herbal agents, castor oil, and enemas have not been scientifically evaluated for their safety or efficacy in cervical ripening or labor induction.

Answer 85

B. Prostaglandins found in semen. Rationale: Human semen contains prostaglandins, which can aid in cervical ripening.

Answer 86

C. It stimulates the release of oxytocin. Rationale: Breast stimulation promotes the release of oxytocin, which can lead to uterine contractions.

Answer 87

C. “The safety and effectiveness of castor oil for labor induction have not been scientifically validated.” Rationale: Castor oil is a nonpharmacologic method whose safety and effectiveness for labor induction have not been validated scientifically.

Answer 88

A. Sexual intercourse with breast stimulation. Rationale: Sexual intercourse releases prostaglandins in semen, while breast stimulation promotes oxytocin release, both of which aid in labor induction.

Answer 89

D. Clients should discuss the use of any complementary methods with their healthcare provider. Rationale: Clients should be advised to consult their healthcare provider regarding the use of complementary methods to ensure safety and appropriate care.

Answer 90

A. Shortened latent phase of labor. Rationale: The Cochrane review found that sexual intercourse with breast stimulation may shorten the latent phase of labor, although safety issues have not been fully evaluated.

Answer 91

C. “The risks and benefits of red raspberry leaves for labor induction are not well-documented.” Rationale: The risks and benefits of herbal agents like red raspberry leaves have not been scientifically studied, so they cannot be recommended for labor induction.

Answer 92

B. The mucus plug acts as a barrier to prevent infections in the cervix. Rationale: The mucus plug is a jelly-like barrier in the cervix that helps prevent infections. Its loss does not necessarily indicate imminent labor, and it can regenerate.

Answer 93

C. “The loss of the mucus plug is normal and does not mean labor will start right away.” Rationale: Losing the mucus plug is a normal part of pregnancy and does not necessarily mean labor is imminent, as the cervix may still take time to prepare for delivery.

Answer 94

B. To detach the amniotic membranes from the cervix to promote cervical ripening Rationale: Membrane stripping involves manual detachment of the amniotic membranes from the cervix to encourage cervical ripening and labor onset.

Answer 95

A. A client with a breech presentation Rationale: Breech presentation increases the risk of umbilical cord prolapse after an amniotomy, making it a contraindication for the procedure.

Answer 96

B. To detect umbilical cord prolapse or compression Rationale: FHR monitoring after an amniotomy is crucial to detect umbilical cord prolapse or compression, which can cause FHR deceleration and jeopardize fetal oxygenation.

Answer 97

C. Meconium-stained fluid Rationale: Meconium-stained fluid may indicate fetal distress, requiring immediate assessment and intervention to ensure fetal well-being.

Answer 98

C. Maternal or neonatal infection Rationale: Membrane stripping increases the risk of introducing pathogens into the uterus, potentially leading to maternal or neonatal infection.

Answer 99

D. Assessing fetal heart rate and amniotic fluid characteristics Rationale: After an amniotomy, the nurse must immediately assess the FHR for signs of umbilical cord prolapse or compression and evaluate the amniotic fluid for characteristics indicating complications.

Answer 100

A. Dinoprostone (Cervidil) Rationale: Dinoprostone (Cervidil) is the only FDA-approved agent for cervical ripening. Misoprostol, while effective, is not FDA-approved for this purpose but is endorsed by ACOG due to its safety and effectiveness.

Answer 101

B. Previous uterine scar Rationale: Misoprostol is contraindicated for women with prior uterine scars, such as those from a cesarean section, because it increases the risk of uterine rupture.

Answer 102

A. Uterine hyperstimulation Rationale: Prostaglandins can induce excessive uterine contractions, leading to uterine hyperstimulation. This can impair uteroplacental blood flow, increase perinatal morbidity, and potentially lead to uterine rupture.

Answer 103

A. 25 to 50 mcg Rationale: Misoprostol is typically administered at doses of 25 to 50 mcg for cervical ripening. Higher doses increase the risk of uterine hyperstimulation and related complications.

Answer 104

C. Its primary indication is gastric ulcer prevention Rationale: Misoprostol was initially developed and FDA-approved for gastric ulcer prevention. Although it is effective for cervical ripening, its use for this purpose is considered off-label.

Answer 105

B. Monitoring fetal heart rate and uterine activity Rationale: Continuous monitoring of fetal heart rate and uterine activity is critical to identify adverse effects such as uterine hyperstimulation or fetal distress.

Answer 106

D. Uterine contractions every 2 minutes lasting 90 seconds Rationale: Uterine contractions every 2 minutes lasting 90 seconds indicate uterine hyperstimulation, which can compromise uteroplacental blood flow and lead to fetal distress. Immediate action is required.

Answer 107

D. “Prostaglandins promote cervical changes and may initiate labor contractions.” Rationale: Prostaglandins are used for cervical ripening as they promote cervical changes and can stimulate uterine contractions. However, they carry risks such as uterine hyperstimulation.

Answer 108

A. Stop the oxytocin infusion Rationale: If uterine hyperstimulation is suspected, the nurse’s first action is to stop the oxytocin infusion to allow the uterus to relax and prevent further fetal compromise. Then, additional interventions can be initiated, such as repositioning and notifying the provider.

Answer 109

C. To minimize uterine hyperstimulation and fetal compromise Rationale: Oxytocin must be carefully titrated to minimize the risk of uterine hyperstimulation, which can compromise fetal oxygenation and increase maternal and perinatal morbidity.

Answer 110

B. Contractions every 2 to 3 minutes lasting 40 to 60 seconds Rationale: The goal is to achieve stable contractions every 2 to 3 minutes, each lasting 40 to 60 seconds, allowing for adequate uterine relaxation and fetal oxygenation between contractions.

Answer 111

C. Potent, short-acting, and easily titratable Rationale: Oxytocin is effective because of its potency, short half-life (1 to 5 minutes), and ease of titration. It is generally well tolerated but requires continuous monitoring due to potential side effects.

Answer 112

B. Resting uterine tone above 20 mm Hg Rationale: Resting uterine tone above 20 mm Hg can indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate intervention to reduce oxytocin dosage.

Answer 113

D. To promote cervical ripening and increase the likelihood of successful induction Rationale: Prostaglandins are used to ripen the cervix in women with low Bishop scores, significantly enhancing the success of labor induction with oxytocin.

Answer 114

B. Headache and vomiting Rationale: Water intoxication due to oxytocin’s antidiuretic effect can result in symptoms such as headache and vomiting.

Answer 115

D. Monitor fetal heart rate and uterine activity continuously Rationale: Continuous monitoring of FHR and uterine activity is necessary to identify complications such as uterine hyperstimulation or fetal hypoxia.

Answer 116

B. Intravenous infusion pump piggybacked into the main IV line Rationale: Oxytocin is administered via an IV infusion pump, piggybacked into the main intravenous line at the port closest to the insertion site. This allows for precise titration of the medication.

Answer 117

C. Uterine hyperstimulation Rationale: The most common adverse effect of oxytocin is uterine hyperstimulation, which can lead to fetal compromise and impaired oxygenation. Continuous fetal heart rate (FHR) monitoring is essential to detect and address this complication.

Answer 118

D. Cervical dilation, effacement, and fetal well-being Rationale: Before labor induction, it is essential to assess the client’s cervical status (dilation and effacement) and ensure fetal well-being through monitoring techniques to determine readiness and the ability to tolerate labor contractions.

Answer 119

D. Reviewing the client’s history for placenta previa Rationale: Rationale: Reviewing the client’s history for contraindications, such as placenta previa, is crucial to prevent complications associated with cervical ripening and labor induction.

Answer 120

C. To predict the likelihood of a successful vaginal delivery Rationale: The Bishop score evaluates cervical readiness for labor and helps predict the likelihood of a successful vaginal delivery. A score over 8 suggests a higher probability of success without cervical ripening.

Answer 121

A. Fetal station at -3 Rationale: A fetal station of -3 indicates that the presenting part is still high in the pelvis, which could decrease the likelihood of a successful induction. A low Bishop score (associated with an unfavorable cervix) may require cervical ripening before induction.

Answer 122

C. Active genital herpes infection Rationale: Active genital herpes infection is a contraindication for labor induction due to the risk of neonatal herpes transmission during vaginal delivery. A cesarean delivery is recommended in such cases.

Answer 123

B. Verifying the client has signed the consent form after understanding the procedure Rationale: The nurse ensures that the client has signed the informed consent form after receiving complete information about the procedure, including risks, benefits, and alternatives, from the healthcare provider. The nurse’s role is to verify understanding, not provide all details of the procedure.

Answer 124

B. “Labor induction involves using various methods to start labor due to medical reasons like high blood pressure or prolonged pregnancy.” Rationale: The nurse should provide a clear and accurate explanation of labor induction, including its purpose and methods. It is often recommended for specific medical reasons such as elevated blood pressure or prolonged pregnancy.

Answer 125

C. Verifying the Bishop score has been assessed and documented Rationale: Ensuring that the Bishop score has been assessed and documented is critical, as it helps predict the success of labor induction and identifies whether cervical ripening is needed.

Answer 126

A. Prolonged pregnancy over 41 weeks Rationale: Prolonged pregnancy beyond 41 weeks is a medical indication for labor induction to reduce risks to both the mother and fetus. Personal preference or advanced maternal age alone is not an indication for induction.

Answer 127

D. “Stripping the membranes and using medications are common ways to induce labor.” Rationale: Stripping the membranes and using medications, such as prostaglandins or oxytocin, are common methods of labor induction. This teaching provides a comprehensive overview of possible approaches.

Answer 128

B. History of uterine scars Rationale: Misoprostol is contraindicated in women with a history of uterine scars (e.g., from cesarean delivery) due to the increased risk of uterine rupture. Hypertension and gestational diabetes are not contraindications for misoprostol use.

Answer 129

A. Monitoring uterine resting tone frequently Rationale: Monitoring uterine resting tone is critical to ensure the uterus relaxes adequately between contractions and to prevent uteroplacental insufficiency.

Answer 130

A. “Notify me if you feel excessive pressure or pain between contractions.” Rationale: Excessive pain or pressure between contractions may indicate uterine hyperstimulation, which requires immediate intervention. Decreased urine output is a sign of water intoxication and is not expected.

Answer 131

B. 1 cm per hour Rationale: Satisfactory labor progress during oxytocin administration is typically indicated by cervical dilation of approximately 1 cm per hour. Slower rates may indicate the need for reassessment of the induction plan.

Answer 132

A. Resting uterine tone Rationale: Resting uterine tone is monitored closely during oxytocin administration to ensure the uterus relaxes between contractions and prevent complications like uteroplacental insufficiency.

Answer 133

B. Maternal vital signs and fetal heart rate Rationale: Frequent monitoring of maternal vital signs and FHR ensures early identification of complications such as uterine hyperstimulation or fetal distress.

Answer 134

D. Encourage the client to empty her bladder every 2 hours Rationale: Encouraging the client to empty her bladder every 2 hours helps prevent soft tissue obstruction and allows for optimal fetal descent.

Answer 135

C. Every 15 minutes Rationale: Continuous FHR monitoring is critical during labor induction with oxytocin. Documentation every 15 minutes during the active phase helps ensure fetal well-being.

Answer 136

D. Category III FHR pattern Rationale: A category III FHR pattern indicates abnormal fetal status and requires immediate discontinuation of oxytocin to address fetal compromise.

Answer 137

B. Discontinue the oxytocin infusion and notify the healthcare provider Rationale: Uterine hyperstimulation requires immediate discontinuation of oxytocin and notification of the healthcare provider to prevent fetal hypoxia and uterine rupture.

Answer 138

D. Set up the infusion using an IV pump and secondary line Rationale: Oxytocin is administered via an IV infusion pump on a secondary line to ensure precise titration and safety. Bolus administration is contraindicated as it can lead to uterine hyperstimulation.

Answer 139

D. Assess the fetal heart rate and maternal vital signs Rationale: While nausea and diarrhea are known side effects of dinoprostone, the nurse should first assess maternal and fetal well-being to rule out additional complications before taking further action.

Answer 140

B. Uterine hyperstimulation Rationale: Uterine hyperstimulation is a critical adverse effect of oxytocin that can impair uteroplacental blood flow and lead to fetal hypoxia or uterine rupture.

Answer 141

C. At least 4 hours after the last dose Rationale: Oxytocin should be initiated at least 4 hours after the last dose of misoprostol to prevent uterine hyperstimulation and adverse fetal outcomes.

Answer 142

B. Headache and vomiting Rationale: Water intoxication due to oxytocin administration can lead to headache, nausea, vomiting, and confusion due to fluid overload and hyponatremia. Hypertension and increased urinary output are not typical signs.

Answer 143

B. Administer terbutaline to reduce uterine activity Rationale: Terbutaline, a tocolytic, is used to manage uterine hyperstimulation and decrease the risk of fetal hypoxia or uterine rupture. Increasing oxytocin would exacerbate hyperstimulation, and fundal pressure is contraindicated in this situation.

Answer 144

D. Monitoring maternal vital signs and fetal heart rate patterns frequently Rationale: Frequent monitoring of maternal vital signs and fetal heart rate patterns is essential to identify any adverse effects, such as uterine hyperstimulation or fetal compromise. Administering oxytocin simultaneously is contraindicated, and upright positioning is unnecessary for dinoprostone.

Answer 145

A. Stop the oxytocin infusion and initiate intrauterine resuscitation Rationale: Contractions occurring every 90 seconds with prolonged durations indicate tachysystole, which can compromise uteroplacental blood flow. The nurse must stop the oxytocin infusion and initiate interventions such as repositioning, oxygen administration, and notifying the provider.

Answer 146

A. To evaluate fetal oxygenation and identify signs of distress Rationale: Continuous FHR monitoring during oxytocin administration is essential to detect fetal distress, which may result from uteroplacental insufficiency caused by uterine hyperstimulation.

Answer 147

B. Discontinue oxytocin infusion and notify the provider Rationale: Tachysystole, defined as excessive uterine contractions, can impair fetal oxygenation. The oxytocin infusion should be discontinued immediately, and the provider notified to prevent complications.

Answer 148

C. Every 30 to 60 minutes by 1-2 mu/min Rationale: Oxytocin infusions are typically increased by 1-2 mu/min every 30 to 60 minutes to achieve adequate contraction patterns without causing uterine tachysystole.

Answer 149

C. 8 Rationale: A Bishop score higher than 8 indicates the cervix is favorable for induction with oxytocin, increasing the likelihood of successful labor. Lower scores suggest the need for cervical ripening before oxytocin administration.

Answer 150

C. “This is likely false labor; drink fluids and walk to see if contractions change.” Rationale: Contractions that are irregular, short in duration, and limited to the lower abdomen are indicative of false labor.

Answer 151

D. Monitor contraction intensity after drinking fluids and walking. Rationale: Drinking fluids and walking can help determine whether contractions are false, as false labor contractions often diminish with these actions.

Answer 152

A. True labor is likely occurring. Rationale: Discomfort starting in the back and radiating to the abdomen is a hallmark of true labor contractions.

Answer 153

B. These are signs of false labor. Rationale: Contractions that are irregular and diminish with ambulation are characteristic of false labor.

Answer 154

A. Frequency, duration, and intensity of contractions Rationale: Assessing contraction patterns (frequency, duration, and intensity) helps determine whether the client is in true labor, which guides further assessments and interventions.

Answer 155

C. Contractions that diminish with walking or position changes Rationale: False labor contractions typically decrease in intensity or stop with walking, activity, or positional changes.

Answer 156

D. “Stay home until the contractions are so strong you cannot talk during one.” Rationale: Contractions in true labor become strong enough to prevent conversation during one. The client should monitor for this change before heading to the hospital.

Answer 157

B. “Stay home until contractions are 5 minutes apart, lasting 45–60 seconds, and strong enough that you can’t talk during one.” Rationale: Clients in early labor are typically advised to stay home until contractions are 5 minutes apart, last 45–60 seconds, and are strong enough to limit conversation during one.

Answer 158

C. Go to the hospital or birthing center. Rationale: Contractions every 5 minutes lasting 60 seconds, combined with discomfort radiating from the back to the abdomen, indicate true labor. The client should proceed to the hospital or birthing center.

Answer 159

D. Drink fluids and ambulate to assess for changes in contraction intensity. Rationale: Irregular contractions that diminish with hydration or activity suggest false labor. Clients can stay home and monitor for changes in intensity or regularity.

Answer 160

C. Contractions that intensify with positional changes Rationale: True labor is characterized by contractions that persist and intensify regardless of positional changes or activity.

Answer 161

D. “Continue monitoring contractions and stay home unless they become more regular and stronger.” Rationale: False labor contractions often decrease with hydration and walking. Clients should stay home unless contractions become regular, stronger, and closer together.

Answer 162

A. Location of discomfort Rationale: In true labor, discomfort begins in the back and radiates to the front of the abdomen. This detail helps distinguish true labor from false labor.

Answer 163

C. True labor contractions increase in strength and continue despite positional changes. Rationale: True labor contractions become stronger with time and persist regardless of activity or positional changes. False labor contractions are irregular and diminish with activity or rest.

Answer 164

C. “Come to the hospital to ensure there are no complications.” Rationale: Bright red bleeding after intercourse, especially late in pregnancy, could indicate a serious complication, such as placenta previa, and requires immediate evaluation.

Answer 165

A. Come to the hospital immediately. Rationale: Rupture of membranes requires immediate medical attention to reduce the risk of infection and to assess for labor progression.

Answer 166

A. Reassure the client that spotting after a vaginal exam is normal. Rationale: Spotting after a vaginal exam is common due to the sensitivity of the cervix. The nurse should reassure the client that this is a normal occurrence.

Answer 167

A. Preeclampsia Rationale: Severe pain in the upper abdomen, along with nausea and vomiting, may indicate preeclampsia, a pregnancy-related condition that requires immediate medical attention.

Answer 168

B. “Come to the hospital immediately for evaluation and monitoring.” Rationale: Rupture of membranes requires immediate medical evaluation to reduce the risk of infection and assess for signs of labor progression.

Answer 169

D. Instruct the client to come to the hospital immediately for fetal monitoring. Rationale: No fetal movement for several hours, particularly at term, may indicate fetal distress. The client should come to the hospital immediately for further evaluation and monitoring.

Answer 170

B. “Stay at home and continue to monitor your contractions.” Rationale: Contractions that are regular but not strong enough to impair conversation typically indicate early labor. The client should stay at home and monitor the situation until contractions become stronger.

Answer 171

A. Preeclampsia Rationale: Severe headaches, vision changes, and swelling, particularly in the hands and face, are symptoms of preeclampsia, which requires immediate medical attention.

Answer 172

B. Instruct the client to come to the hospital immediately for evaluation. Rationale: Bright red bleeding that is not associated with cervical sensitivity after an exam or intercourse could indicate a serious complication, such as placenta previa or abruptio placenta, and requires immediate evaluation.

Answer 173

D. “It’s important to come to the hospital immediately for fetal monitoring.” Rationale: Decreased fetal movement, particularly when it is less than 10 movements in 2 hours, can indicate fetal distress, and the nurse should advise the client to come to the hospital for evaluation.

Answer 174

A. “Go to the hospital immediately regardless of contractions.” Rationale: Rupture of membranes requires immediate medical attention, even if contractions have not started. The nurse should advise the client to go to the hospital immediately.

Answer 175

C. “Stay at home until your contractions become stronger and last for one minute.” Rationale: Contractions in early labor can be irregular and may not cause difficulty in talking. The client should stay home until contractions are stronger and last 60 seconds.

Answer 176

B. The fundus is at the level of the umbilicus and firm. Rationale: Within the first 12 hours postpartum, the fundus is typically at the level of the umbilicus and should be firm. A fundus above the umbilicus or not firm may indicate complications such as uterine atony or retained placental fragments.

Answer 177

A. The uterus descends approximately 1 cm per day. B. By 10 days postpartum, the uterus is no longer palpable. D. Lochia is present as the upper layer of the decidua sloughs off. Rationale: Uterine involution involves the uterus descending about 1 cm per day, becoming non-palpable by 10 days postpartum. Lochia occurs due to sloughing of the upper decidual layer. The uterus shrinks by 50% within 1 week, not 3 days, and the fundus should descend daily, not remain at the umbilicus for 7 days.

Answer 178

C. 5 cm below the umbilicus Rationale: The uterus descends approximately 1 cm per day postpartum. By day 5, the fundus should be about 5 cm (or 5 fingerbreadths) below the umbilicus, indicating normal uterine involution.

Answer 179

D. Perform a fundal massage and reassess. Rationale: A soft, elevated fundus on day 3 postpartum is abnormal and may indicate uterine atony. The nurse should perform a fundal massage to promote uterine contractions and reassess. If the fundus remains soft, further interventions, such as notifying the healthcare provider, may be necessary.

Answer 180

C. Catabolism of uterine muscle cells Rationale: Catabolism is the process by which muscle cells and fibers shrink, leading to the gradual reduction in uterine size postpartum. Regeneration of epithelial tissue and sloughing of the decidua contribute to lochia production, while hormonal changes support the overall process.

Answer 181

A. “Lochia occurs because the uterus is healing after delivery.” Rationale: Lochia results from the sloughing of the upper layer of the decidua and the regeneration of the uterine epithelium as the uterus heals after delivery. It is a normal part of the postpartum period.

Answer 182

A. “My uterus will shrink by half within the first week.” B. “The fundus will descend about 1 cm each day.” D. “By 10 days postpartum, my uterus will not be palpable in my abdomen.” Rationale: The uterus shrinks by approximately 50% within the first week, descends about 1 cm per day, and is typically non-palpable by day 10. Lochia is a normal sign of healing, not an indicator of improper healing. It takes several weeks for the uterus to return to its normal size.

Answer 183

C. Assist the client in emptying her bladder. Rationale: A full bladder can displace the uterus, inhibiting proper involution and increasing the risk of postpartum hemorrhage. Assisting the client to empty her bladder can promote uterine descent. Fundal massage is unnecessary unless the uterus is soft or boggy.

Answer 184

C. Retained placental fragments Rationale: Retained placental fragments interfere with uterine contraction and healing, leading to subinvolution. Breastfeeding and early ambulation promote uterine involution through stimulation of uterine contractions and improved circulation, while a complication-free labor minimizes uterine trauma.

Answer 185

A. Breastfeeding D. Complete expulsion of the placenta E. Early ambulation Rationale: Breastfeeding, complete expulsion of the placenta, and early ambulation facilitate uterine involution by promoting uterine contractions and ensuring the uterus remains empty and active. A full bladder and uterine infection inhibit involution.

Answer 186

B. The fundus is not palpable in the abdomen. Rationale: By day 10 postpartum, the uterus has descended into the true pelvis and is no longer palpable in the abdomen, indicating normal involution. A fundus at or above the umbilicus at this stage is abnormal and suggests subinvolution.

Answer 187

D. Catabolism Rationale: Catabolism is the process that shrinks enlarged myometrial cells during uterine involution. Muscle fiber contraction reduces the stretched uterus, and epithelial regeneration replaces the sloughed decidua, while lochial discharge is a byproduct of the process.

Answer 188

A. A large singleton fetus Rationale: Overdistention of uterine muscles, such as from a large singleton fetus, can inhibit involution by decreasing uterine tone and delaying contraction. Early ambulation and breastfeeding promote involution, and a complication-free delivery minimizes uterine trauma.

Answer 189

C. Subinvolution of the uterus Rationale: Subinvolution occurs when the uterus fails to descend as expected, often due to factors such as retained placental fragments or infection. A uterus above the umbilicus on day 7 is abnormal and indicative of subinvolution.

Answer 190

D. Promoting frequent breastfeeding sessions Rationale: Breastfeeding stimulates oxytocin release, which promotes uterine contractions and involution. Hydration supports recovery but does not directly impact uterine contraction. Uterine massage is only indicated for a soft or boggy uterus, and bedrest is not recommended unless medically necessary.

Answer 191

A. A soft uterus on palpation B. Fundus at the level of the umbilicus on day 7 postpartum D. Foul-smelling lochia E. Heavy vaginal bleeding Rationale: Subinvolution may present as a soft uterus, a high fundal height for the postpartum day, foul-smelling lochia (indicative of infection), and heavy bleeding. Proper progression of lochia (rubra to serosa to alba) indicates normal involution.

Answer 192

D. “It takes about 6 weeks for your uterus to fully return to its prepregnant size.” Rationale: Uterine involution typically takes about 6 weeks for the uterus to return to its prepregnant size, although it becomes non-palpable in the abdomen by day 10. The stopping of lochia does not necessarily correlate with the completion of involution.

Answer 193

B. Persistent foul-smelling lochia on postpartum day 5 Rationale: Persistent foul-smelling lochia may indicate infection, a key cause of subinvolution. By postpartum day 5, lochia should transition to serosa. Fundal height two fingerbreadths below the umbilicus on day 2 is normal, as is moderate lochia rubra on day 3. Mild cramping and tenderness are expected immediately postpartum.

Answer 194

C. Retained placental fragments Rationale: Retained placental fragments are the most common cause of subinvolution as they prevent the uterus from fully contracting and returning to its nonpregnant size. The other factors contribute to subinvolution but are less common in the immediate postpartum period.

Answer 195

A. Full bladder C. Polyhydramnios D. Prolonged labor E. Large baby Rationale: A full bladder, polyhydramnios, prolonged labor, and a large baby all contribute to uterine overdistension or incomplete contraction, increasing the risk of subinvolution. Breastfeeding promotes uterine contraction and facilitates involution.

Answer 196

C. “Breastfeeding increases my risk of subinvolution.” Rationale: Breastfeeding stimulates oxytocin release, which promotes uterine contraction and reduces the risk of subinvolution. The other statements correctly identify risk factors for subinvolution.

Answer 197

C. Perform a fundal massage. Rationale: A soft (boggy) uterus requires immediate fundal massage to stimulate contraction and prevent hemorrhage. Once stabilized, further assessment and interventions, such as breastfeeding or imaging, can be performed as needed.

Answer 198

A. Lochia rubra persisting beyond the normal timeframe B. Fundus palpable above the umbilicus on day 7 E. Heavy vaginal bleeding Rationale: Persistent lochia rubra, a high fundal height, and heavy vaginal bleeding are indicative of subinvolution. A firm uterus and decreased lochia flow are signs of normal involution.

Answer 199

A. Postpartum hemorrhage Rationale: A full bladder displaces the uterus and inhibits contractions, increasing the risk of postpartum hemorrhage. While endometritis and urinary tract infections are possible postpartum complications, they are not directly caused by subinvolution and a full bladder.

Answer 200

B. “The external os changes from a round shape to a jagged slit after vaginal delivery.” Rationale: After childbirth, the external os changes from a round shape to a jagged slit, which is a normal postpartum finding.

Answer 201

C. The cervix is firming up and shortening but remains slightly dilated. Rationale: Within 12 to 18 hours postpartum, the cervix begins to firm up, shorten, and close gradually but remains slightly dilated.

Answer 202

B. “The cervical os will return to its pre-pregnancy round shape after childbirth.” Rationale: The cervical os does not return to its pre-pregnancy round shape; instead, it appears as a jagged slit postpartum.

Answer 203

C. Educate the client that this is a normal finding. Rationale: It is normal for the cervix to be soft and slightly open immediately after birth. Over the next 12 to 18 hours, it gradually firms and closes.

Answer 204

A. “The external os of my cervix will never regain its pre-pregnancy circular shape.” Rationale: The external cervical os does not regain its pre-pregnancy circular shape but instead appears as a jagged slit postpartum.

Answer 205

B. Document the findings as normal in the first postpartum days. Rationale: It is normal for the cervix to remain edematous, bruised, and partly dilated immediately after childbirth. This does not require intervention.

Answer 206

D. 6 weeks postpartum Rationale: The cervix typically returns to its prepregnant state by 6 weeks postpartum.

Answer 207

D. “The external cervical os completely closes and regains its prepregnancy appearance.” Rationale: The external os does not completely close or regain its prepregnancy circular appearance but instead remains wider and slit-like.

Answer 208

A. Absence of vaginal rugae and edematous vaginal walls Rationale: In the early postpartum period, the vaginal walls are edematous, and rugae are absent. The vaginal epithelium and thickness take 6 to 10 weeks to fully restore.

Answer 209

B. “My vaginal walls will remain edematous for several weeks.” Rationale: The vaginal walls appear edematous immediately after childbirth, and rugae begin to reappear by 3 to 4 weeks, with complete epithelium restoration occurring in 6 to 10 weeks.

Answer 210

B. 3 to 4 weeks Rationale: Vaginal rugae begin to reappear around 3 to 4 weeks postpartum.

Answer 211

A. “Your vaginal walls will regain thickness in about 6 weeks.” Rationale: The vaginal walls begin to regain thickness and return to a more normal state around 6 weeks postpartum.

Answer 212

D. “These small lacerations are normal and common after childbirth.” Rationale: Multiple small lacerations are common in the vaginal area after childbirth and typically heal without complications.

Answer 213

C. 6 to 10 weeks Rationale: The vaginal epithelium is typically restored over a period of 6 to 10 weeks postpartum.

Answer 214

B. Reassure the client that these changes are normal and temporary. Rationale: It is normal for the vaginal mucosa to be thin, relaxed, and edematous with few rugae shortly after birth. These changes resolve over time as the body heals, and the mucosa thickens and rugae return in approximately 3 weeks.

Answer 215

B. “It will take about 6 to 8 weeks for your vagina to return to its pre-pregnancy size, although it will always be a bit larger.” Rationale: The vagina generally returns to its approximate pre-pregnancy size within 6 to 8 weeks postpartum but will always be slightly larger than before pregnancy.

Answer 216

D. “I will experience vaginal dryness and discomfort until my menstruation returns.” Rationale: Many women experience localized dryness and coital discomfort (dyspareunia) until menstruation returns. Water-soluble lubricants can help reduce discomfort during intercourse.

Answer 217

C. Edematous, relaxed vaginal mucosa with few rugae Rationale: Immediately after childbirth, the vaginal mucosa is edematous, relaxed, and thin with few rugae. This is a normal finding in the early postpartum period.

Answer 218

B. Trauma from childbirth, including stretching and possible laceration Rationale: The perineum often experiences trauma during childbirth due to stretching to accommodate the fetal head. This trauma typically results in bruising, edema, and sometimes lacerations or hematomas. Healing usually takes 4-6 weeks.

Answer 219

A. Recommend the use of Witch Hazel (Tuck’s) and Dermaplast spray for relief. Rationale: Witch Hazel (Tuck’s) and Dermaplast spray are often used to provide relief from perineal discomfort, bruising, and edema. Proper perineal care with a spray bottle is also important for hygiene.

Answer 220

D. “Gently clean the perineum with warm water using a peri bottle after each void.” Rationale: Gentle cleaning of the perineum with a peri bottle using warm water helps maintain hygiene while reducing the risk of infection. Avoiding harsh cleaning methods is important to prevent further irritation.

Answer 221

A. Administer an analgesic and apply ice to the perineal area. Rationale: Ice can be applied to the perineal area to reduce swelling and pain. Analgesics can be used for comfort. Hematomas and bruising are expected after childbirth and usually resolve with proper care.

Answer 222

C. Perineal edema and bruising that will gradually improve over the next few weeks Rationale: Perineal edema, bruising, and trauma (including lacerations) are common following vaginal delivery and typically heal over the course of 4-6 weeks. Some degree of discomfort may persist during this period.

Answer 223

B. “I will clean the perineum with soap and water after every void.” Rationale: The client should use a peri bottle with warm water to rinse the perineum, not soap and water, to avoid irritation. The other statements are appropriate and indicate proper understanding of perineal care.

Answer 224

D. Infection at the perineal site Rationale: Infection at the perineal site, such as endometritis or cellulitis, can delay the healing process. Other factors like limited ambulation or inadequate self-care may contribute but are not as likely to cause significant delay as infection.

Answer 225

D. Use witch hazel pads, sitz baths, and anesthetic sprays for pain relief. Rationale: Witch hazel pads, sitz baths, and anesthetic sprays can effectively relieve perineal pain and promote healing. Pelvic floor muscle training (PFMT) should not begin immediately after delivery due to the need for proper recovery time.

Answer 226

A. Increase fiber intake and ensure adequate hydration to prevent constipation. Rationale: Increasing fiber intake and staying hydrated can help prevent constipation, reducing strain during bowel movements, which may cause discomfort at the laceration site. Cold compresses are typically used for immediate pain relief, not specifically for bowel movements.

Answer 227

B. “Healing of a perineal laceration can take 4 to 6 months, especially if complications arise.” Rationale: Perineal lacerations typically take 4 to 6 months to heal fully, especially in the presence of complications. PFMT exercises help strengthen the pelvic floor but are not typically recommended immediately after childbirth.

Answer 228

C. Practice pelvic floor muscle training (PFMT) exercises regularly to improve muscle tone. Rationale: Regular pelvic floor muscle training (PFMT) exercises help improve pelvic floor muscle tone, strengthen the perineal muscles, and prevent dysfunction. Starting these exercises once the client is ready can help promote healing and restore pelvic floor strength.

Answer 229

A. Document the finding as bradycardia and monitor for further changes. Rationale: Bradycardia (40–60 bpm) during the first 2 weeks postpartum is an expected finding due to the increased blood flow back to central circulation after delivery. This adaptation allows the heart to pump efficiently at a slower rate.

Answer 230

A. Blood pressure and uterine tone Rationale: Tachycardia in a postpartum patient may indicate hypovolemia or hemorrhage. Assessing blood pressure and uterine tone will help identify potential causes such as uterine atony or excessive bleeding.

Answer 231

A. Notify the healthcare provider immediately for evaluation of preeclampsia. Rationale: A significant increase in blood pressure accompanied by headache may indicate postpartum preeclampsia, a potentially life-threatening condition. Immediate notification of the healthcare provider is critical for further evaluation and treatment.

Answer 232

C. Increased lochia with large clots Rationale: A drop in blood pressure combined with increased lochia and the passage of large clots is indicative of hemorrhage. Bradycardia is not consistent with hemorrhage, and a firm fundus would rule out uterine atony.

Answer 233

C. “It’s normal for my blood pressure to drop a lot during the first few days.” Rationale: While a slight decrease in blood pressure is expected postpartum, a significant drop is not normal and may indicate complications such as hemorrhage or infection. This statement reflects a misunderstanding of normal postpartum changes.

Answer 234

D. Assess for additional signs of infection, such as fever or localized pain. Rationale: Tachycardia and slightly elevated blood pressure in the absence of hemorrhage may indicate infection. Additional assessment for fever, localized pain, or other signs of infection is essential.

Answer 235

B. Administer IV fluids to address potential hypovolemia. Rationale: A blood pressure of 90/60 mmHg with lightheadedness suggests hypovolemia, which may be caused by hemorrhage or dehydration. Administering IV fluids is a priority intervention to stabilize the patient.

Answer 236

B. Postpartum hemorrhage due to uterine displacement Rationale: A full bladder can displace the uterus, preventing it from contracting effectively and leading to excessive vaginal bleeding. Emptying the bladder is critical to resolving this issue.

Answer 237

A. Reassure the patient that this is expected postpartum diuresis. Rationale: Postpartum diuresis is a normal process where the body eliminates excess fluid retained during pregnancy, often resulting in increased urination.

Answer 238

C. Urinary retention with overflow Rationale: Frequent voiding of small amounts (<150 mL) suggests urinary retention with overflow. This condition requires catheterization to empty the bladder and restore tone.

Answer 239

D. Assist the patient to void. Rationale: A uterus displaced to the right is often caused by bladder distention. Assisting the patient to void may correct the displacement and reduce the risk of complications, such as postpartum hemorrhage.

Answer 240

B. Postpartum hemorrhage Rationale: Inability to void can lead to urinary retention, bladder distention, and uterine displacement, which may prevent proper uterine contraction and increase the risk of postpartum hemorrhage.

Answer 241

B. Perform a bladder scan to assess for urinary retention. Rationale: Small voids (<150 mL) may indicate urinary retention with overflow. A bladder scan can confirm retention and guide further intervention, such as catheterization.

Answer 242

A. Declining levels of oxytocin B. Decreasing aldosterone production C. Retention of extra fluids during pregnancy E. Administration of IV fluids during labor Rationale: Postpartum diuresis results from a decline in oxytocin (antidiuretic effect), decreased aldosterone production (increased sodium and water excretion), retained fluids from pregnancy, and IV fluid administration during labor.

Answer 243

C. Assess for perineal lacerations and hematomas. Rationale: Burning during urination and swelling near the urinary meatus may indicate perineal lacerations or hematomas, which can impede urination and increase discomfort.

Answer 244

C. “I don’t need to worry about my bladder if I feel like I’m urinating enough.” Rationale: Postpartum urinary retention can occur even if the patient is voiding frequently. The nurse should emphasize the importance of monitoring voiding patterns and bladder emptying.

Answer 245

A. Bladder distention and incomplete emptying Rationale: Bladder distention and incomplete emptying can lead to urinary stasis, increasing the risk of a UTI.

Answer 246

B. Urinary retention and bladder distention Rationale: Urinary retention and bladder distention can displace the uterus and prevent it from contracting effectively, leading to uterine atony and postpartum hemorrhage.

Answer 247

A. A patient who received a spinal block during labor Rationale: A spinal block can impair neural function, reducing bladder sensation and increasing the risk of urinary retention postpartum.

Answer 248

A. Document this finding as normal. Rationale: Elevated GFR and renal plasma flow typically persist for a few days postpartum as the body clears excess fluid.

Answer 249

B. “Kegel exercises can help improve bladder tone.” Rationale: Kegel exercises strengthen pelvic floor muscles, aiding in the recovery of bladder tone and reducing urinary incontinence.

Answer 250

D. Catheterize the patient to empty the bladder immediately. Rationale: A full bladder can displace the uterus, preventing proper contraction and causing excessive bleeding. Immediate bladder emptying is necessary to restore uterine tone.

Answer 251

B. A patient who had a cesarean birth with a Foley catheter in place Rationale: A Foley catheter increases the risk of introducing bacteria into the urinary tract, making UTIs more likely in patients who underwent cesarean birth.

Answer 252

C. “It’s okay to delay voiding if I’m feeling comfortable.” Rationale: Delaying voiding can lead to urinary stasis, increasing the risk of infection. The nurse should emphasize the importance of regular bladder emptying.

Answer 253

B. Notify the healthcare provider immediately. Rationale: A temperature above 100.4°F (38°C) after the first 24 hours postpartum may indicate an infection, requiring prompt reporting and investigation.

Answer 254

C. “It is likely due to dehydration from fluid loss during labor and will normalize with hydration.” Rationale: A slight elevation in temperature (up to 100.4°F) during the first 24 hours postpartum is typically due to dehydration from fluid loss during labor and resolves with hydration.

Answer 255

B. Foul-smelling lochia Rationale: A temperature above 100.4°F postpartum combined with foul-smelling lochia is a strong indicator of infection, such as endometritis, requiring immediate intervention.

Answer 256

C. Notify the healthcare provider and anticipate a blood culture order. Rationale: An elevated temperature in a client with risk factors such as prolonged labor or rupture of membranes may indicate infection. Reporting the finding and preparing for diagnostic testing is essential.

Answer 257

D. “I can expect my temperature to remain slightly elevated for the first 48 hours.” Rationale: A temperature elevation should normalize after the first 24 hours postpartum. Persistent elevation beyond this period may indicate infection and requires further evaluation.

Answer 258

A. “This is called puerperal bradycardia, which is normal after delivery.” Rationale: Puerperal bradycardia (pulse of 60–80 bpm) is a normal finding in the first week postpartum due to increased stroke volume following delivery.

Answer 259

D. The client reports dizziness and increased thirst. Rationale: Tachycardia, along with dizziness and increased thirst, may indicate hypovolemia from excessive blood loss or dehydration, requiring immediate evaluation and intervention.

Answer 260

A. “A slower pulse rate during the first week after birth is expected.” Rationale: Puerperal bradycardia, with a resting pulse of 60–80 bpm, is a normal finding postpartum due to increased stroke volume.

Answer 261

C. A client with a pulse of 102 bpm and moderate vaginal bleeding Rationale: A pulse rate over 100 bpm postpartum may indicate complications such as excessive blood loss or infection and warrants further investigation, especially if accompanied by vaginal bleeding.

Answer 262

D. Notify the healthcare provider and assess for signs of infection. Rationale: Tachycardia and an elevated temperature postpartum are abnormal and suggest potential infection, such as endometritis or sepsis, requiring immediate reporting and assessment.

Answer 263

B. A client with a history of asthma reporting chest tightness and a respiratory rate of 22 breaths per minute Rationale: A postpartum client with a history of asthma and an elevated respiratory rate may be at risk for complications such as pulmonary embolism or exacerbation of asthma and should be monitored closely.

Answer 264

A. Document the findings as normal. Rationale: A respiratory rate within the normal range (12–20 breaths per minute) and clear lung sounds indicate normal postpartum respiratory function.

Answer 265

B. Effects of epidural anesthesia Rationale: A respiratory rate below the normal range (12–20 breaths per minute) in a postpartum client may indicate respiratory depression, which can be a side effect of epidural anesthesia.

Answer 266

C. Auscultate the lung fields for abnormalities. Rationale: The nurse should first assess the lung fields to identify any abnormalities, such as crackles or diminished breath sounds, which may help determine if the client is experiencing pulmonary complications.

Answer 267

B. Pulmonary edema Rationale: Crackles in the lungs accompanied by an elevated respiratory rate suggest pulmonary edema, which can be a serious postpartum complication.

Answer 268

A. Place the client in a supine position with her legs elevated. Rationale: The client is likely experiencing hypotension due to epidural anesthesia. Placing her in a supine position with legs elevated promotes venous return and stabilizes blood pressure.

Answer 269

B. Increased respiratory rate and cool, clammy skin Rationale: Hypovolemic shock is characterized by hypotension, increased respiratory rate, and signs of poor perfusion such as cool, clammy skin.

Answer 270

C. Advise the client to rise slowly and assist her as needed. Rationale: Orthostatic hypotension can occur postpartum. The priority intervention is to advise the client to rise slowly and provide assistance to prevent falls or injury.

Answer 271

C. Take the blood pressure with the client in the same position as previous assessments. Rationale: Blood pressure can vary based on positioning; assessing it in the same position each time ensures consistency and accuracy in identifying trends or abnormalities.

Answer 272

D. Gestational hypertension Rationale: A blood pressure reading above 140/90 mm Hg postpartum may indicate gestational hypertension. This finding should be monitored and reported to the healthcare provider.

Answer 273

A. Apply an ice pack to the perineal area. Rationale: Applying an ice pack is the first-line intervention for swelling and pain in the perineal area, as it reduces inflammation and provides comfort.

Answer 274

A. Provide routine analgesics before assessments. Rationale: Preventing pain through routine analgesics is a key strategy in postpartum care, ensuring the client remains comfortable during assessments.

Answer 275

B. Repositioning the client frequently. Rationale: Perineal care helps reduce discomfort by maintaining cleanliness, preventing infection, and promoting healing in the affected area.

Answer 276

A. Administer the prescribed analgesic as requested. Rationale: Pain is subjective, and the nurse should believe the client’s self-report. Administering the prescribed analgesic ensures comfort and supports healing.

Answer 277

B. Administer prescribed analgesics before breastfeeding. Rationale: Afterbirth pains often intensify after breastfeeding due to uterine contractions. Administering analgesics beforehand helps manage this pain effectively.

Answer 278

B. Inspect and palpate the perineal area for a hematoma. Rationale: Severe perineal pain that does not respond to routine measures may indicate a hematoma. The nurse should assess for this and notify the healthcare provider if one is found.

Answer 279

D. “A temperature of 100.5°F or higher could mean I have an infection.” Rationale: A postpartum temperature higher than 100.4°F (38°C) is a potential sign of infection and requires prompt reporting and evaluation.

Answer 280

B. Postpartum hemorrhage Rationale: Uterine overdistention from a twin pregnancy increases the risk of uterine atony, which can lead to postpartum hemorrhage.

Answer 281

B. Monitor closely for signs of retained placental fragments. Rationale: Manual extraction of the placenta increases the risk of retained fragments, which can lead to hemorrhage or infection.

Answer 282

B. Postpartum infection Rationale: Prolonged labor, use of an indwelling urinary catheter, and multiple vaginal examinations are significant risk factors for postpartum infection.

Answer 283

B. Administer oxytocin as prescribed. Rationale: Uterine atony is the leading cause of postpartum hemorrhage, and administering oxytocin helps stimulate uterine contractions to control bleeding.

Answer 284

D. A client with hydramnios and a prolonged third stage of labor Rationale: Hydramnios and a prolonged third stage of labor increase the risk of uterine overdistention and retained placental fragments, leading to postpartum hemorrhage.

Answer 285

C. Postpartum infection Rationale: Anemia (hemoglobin <10.5 mg/dL) increases the risk of postpartum infection due to reduced immune function and impaired healing.

Answer 286

C. Uterine tenderness with foul-smelling lochia Rationale: Uterine tenderness with foul-smelling lochia suggests infection, which is a serious postpartum complication requiring prompt intervention.

Answer 287

A. Assessing for uterine atony and hemorrhage Rationale: Precipitous labor increases the risk of uterine atony and postpartum hemorrhage due to the rapid delivery and potential trauma to uterine muscles.

Answer 288

B. Monitor the client’s temperature and lochia characteristics. Rationale: Prolonged rupture of membranes increases the risk of infection; monitoring temperature and lochia can help identify early signs of endometritis.

Answer 289

B. Monitor closely for signs of retained placental fragments. Rationale: Manual extraction of the placenta increases the risk of retained fragments, which can lead to hemorrhage or infection.

Answer 290

A. Postpartum hemorrhage Rationale: Uterine overdistention from a twin pregnancy increases the risk of uterine atony, which can lead to postpartum hemorrhage.

Answer 291

B. “A temperature of 100.5°F or higher could mean I have an infection.” Rationale: A postpartum temperature higher than 100.4°F (38°C) is a potential sign of infection and requires prompt reporting and evaluation.

Answer 292

A. Postpartum infection Rationale: Prolonged labor, use of an indwelling urinary catheter, and multiple vaginal examinations are significant risk factors for postpartum infection.

Answer 293

B. Administer oxytocin as prescribed. Rationale: Uterine atony is the leading cause of postpartum hemorrhage, and administering oxytocin helps stimulate uterine contractions to control bleeding.

Answer 294

A. A client with hydramnios and a prolonged third stage of labor Rationale: Hydramnios and a prolonged third stage of labor increase the risk of uterine overdistention and retained placental fragments, leading to postpartum hemorrhage.

Answer 295

C. Postpartum infection Rationale: Anemia (hemoglobin <10.5 mg/dL) increases the risk of postpartum infection due to reduced immune function and impaired healing.

Answer 296

C. Uterine tenderness with foul-smelling lochia Rationale: Uterine tenderness with foul-smelling lochia suggests infection, which is a serious postpartum complication requiring prompt intervention.

Answer 297

A. Assessing for uterine atony and hemorrhage Rationale: Precipitous labor increases the risk of uterine atony and postpartum hemorrhage due to the rapid delivery and potential trauma to uterine muscles.

Answer 298

D. Monitor the client’s temperature and lochia characteristics. Rationale: Prolonged rupture of membranes increases the risk of infection; monitoring temperature and lochia can help identify early signs of endometritis.

Answer 299

B. Assess for signs of pulmonary edema or embolism Rationale: Shortness of breath without exertion is a potential sign of pulmonary embolism or edema, both of which are life-threatening conditions requiring immediate assessment and intervention.

Answer 300

A. Endometritis Rationale: Foul-smelling lochia is a classic symptom of endometritis, a postpartum uterine infection that requires prompt treatment with antibiotics.

Answer 301

D. Notify the healthcare provider immediately Rationale: Calf pain with dorsiflexion (positive Homan’s sign) suggests a possible deep vein thrombosis (DVT), a serious condition that requires immediate medical attention.

Answer 302

B. Saturation of a peripad within 1 hour Rationale: Saturating a peripad within an hour indicates heavy bleeding, a potential sign of postpartum hemorrhage that requires immediate intervention.

Answer 303

C. Urinary tract infection (UTI) Rationale: Dysuria and burning are classic signs of a UTI, which is a common postpartum complication due to catheter use or trauma during delivery.

Answer 304

B. Perform a neurological assessment and monitor blood pressure Rationale: Severe headache and blurred vision are potential signs of preeclampsia, requiring a neurological assessment and blood pressure monitoring to identify hypertensive complications.

Answer 305

B. Blood and decidual and trophoblastic debris Rationale: Lochia rubra primarily contains blood, decidual, and trophoblastic debris. This stage typically lasts for the first three days postpartum.

Answer 306

B. Lochia serosa Rationale: Lochia serosa occurs from days 4 through 10 postpartum and is characterized by old blood, serum, leukocytes, and debris, which can give the discharge a red to yellow tinge.

Answer 307

D. “Lochia alba should stop by the end of the second week.” Rationale: Lochia alba typically lasts beyond the second week and can persist for several weeks. The other statements reflect correct understanding.

Answer 308

C. Perform fundal massage to firm the uterus. Rationale: A boggy uterus indicates uterine atony, which can lead to excessive lochia rubra. The priority is to perform a fundal massage to promote uterine contraction and reduce bleeding.

Answer 309

A. Tachycardia B. Hypotension D. Tachypnea Rationale: Significant blood loss (30–40% of total blood volume) can lead to tachycardia, hypotension, and tachypnea as compensatory mechanisms for hypovolemia. Hypertension and decreased oxygen saturation are not typical early findings in postpartum hemorrhage.

Answer 310

C. Uterine infection. Rationale: Foul-smelling lochia is often a sign of uterine infection (endometritis). Retained placental fragments and uterine overdistension can contribute to infection, but the primary concern is the infection itself.

Answer 311

C. Notify the healthcare provider. Rationale: Lochia transitioning back to rubra (from serosa or alba) after day 4–5 postpartum may indicate subinvolution or infection, requiring prompt evaluation and intervention.

Answer 312

B. “Lochia may continue for 4 to 8 weeks postpartum.” Rationale: Lochia can persist for 4 to 8 weeks postpartum as the endometrium undergoes restoration. While cesarean births tend to have less lochia due to manual debris removal, duration is not solely dependent on delivery mode.

Answer 313

C. Suggestive of delayed involution Rationale: Lochia serosa typically transitions to lochia alba by day 10. Persistence of serosa beyond this time may indicate delayed involution, requiring further evaluation.

Answer 314

A. Leukocytes, decidual tissue, and reduced fluid content Rationale: Lochia alba, the final stage of lochia, is characterized by leukocytes, decidual tissue, and reduced fluid content. It is creamy white or light brown in color.

Answer 315

A. Lochia with an offensive odor B. Bright red lochia on day 15 D. Lochia transitioning from alba back to rubra E. Heavy flow with large clots Rationale: Lochia with a foul odor indicates infection. Bright red lochia or a transition back to rubra after day 4–10 may indicate subinvolution or infection. Heavy flow with large clots is also abnormal. Creamy white lochia on day 11 is normal for lochia alba.

Answer 316

A. “This is a normal finding during the postpartum period.” Rationale: Lochia at any stage should have a fleshy odor. An offensive or foul odor, however, is not normal and should be reported.

Answer 317

B. Pinkish brown lochia with leukocytes and serous fluid Rationale: By day 5 postpartum, the lochia is typically in the serosa stage, characterized by a pinkish-brown color with leukocytes, decidual tissue, red blood cells, and serous fluid.

Answer 318

D. Cesarean birth Rationale: Cesarean births tend to result in less lochia because uterine debris is manually removed during surgery, reducing the amount of discharge postpartum.

Answer 319

D. “I’ll use scented lotions to keep my nipples moisturized.” Rationale: Scented lotions can cause irritation and are not recommended for breast care. Moisturization should be done using natural methods like lanolin cream or expressed breast milk.

Answer 320

D. “Apply a lanolin-based cream or breast milk to the nipples after feeding.” Rationale: Lanolin cream or breast milk can soothe and promote healing of cracked nipples. Soap, alcohol, or avoiding a bra may exacerbate the problem.

Answer 321

A. “Wear a snug, supportive bra continuously until the engorgement resolves.” Rationale: A snug, supportive bra helps alleviate discomfort and promote resolution of engorgement. Warm compresses and expressing milk are only recommended for breastfeeding mothers.

Answer 322

B. “Use plain water to clean your breasts, avoiding soap on the nipples.” Rationale: Plain water is recommended for breast hygiene as soap can dry the nipples and lead to cracking, increasing the risk of infection.

Answer 323

A. “I will check for signs of redness, bruising, or bleeding on my nipples daily.” Rationale: Monitoring for nipple changes such as redness, bruising, or bleeding is crucial to identify potential issues early. Avoiding feeding or touching nipples can exacerbate problems. Soft breasts may indicate adequate milk removal, not the need to reduce feeding frequency.

Answer 324

B. A red, warm area is present on one breast. Rationale: A red, warm area on the breast could indicate mastitis, which requires prompt intervention to prevent complications.

Answer 325

B. Apply lanolin cream or expressed breast milk to the nipples after each feeding. Rationale: Lanolin cream or expressed breast milk can promote healing and protect the nipples. Soap and water can cause further dryness and irritation.

Answer 326

A. Encourage the client to apply cold compresses between feedings. Rationale: Cold compresses between feedings help reduce swelling and relieve discomfort caused by engorgement. Warm compresses and massage are only appropriate just before feeding to assist with milk let-down.

Answer 327

B. A red, warm area is present on one breast. Rationale: A red, warm area on the breast could indicate mastitis, which requires prompt intervention to prevent complications.

Answer 328

A. “I will check for signs of redness, bruising, or bleeding on my nipples daily.” Rationale: Monitoring for nipple changes such as redness, bruising, or bleeding is crucial to identify potential issues early. Avoiding feeding or touching nipples can exacerbate problems. Soft breasts may indicate adequate milk removal, not the need to reduce feeding frequency.

Answer 329

D. Use ice packs or cool compresses and change them every 30 minutes. Rationale: Ice packs or cool compresses help reduce local pain and swelling. Warm water or breast binding can stimulate milk production or cause discomfort.

Answer 330

C. Drink to quench thirst without restricting fluid intake. Rationale: Restricting fluids does not help dry up milk; drinking enough to quench thirst is recommended to stay hydrated.

Answer 331

D. Take mild analgesics to reduce breast pain. Rationale: Mild analgesics are appropriate for reducing breast discomfort. Breast massage, loose-fitting bras, and warm compresses may stimulate milk production.

Answer 332

C. Use ice packs or cool compresses to decrease pain and swelling. Rationale: Cool compresses help decrease swelling and pain without stimulating milk production. Pumping, latching, and increased salt intake are inappropriate.

Answer 333

B. “I should let warm water from the shower flow over my breasts to relieve pain.” Rationale: Warm water flowing over the breasts can stimulate milk production and should be avoided; cool compresses are recommended instead.

Answer 334

C. 5 to 7 days Rationale: Lactation suppression typically takes 5 to 7 days, and the mother should follow the recommended guidelines during this period.

Answer 335

B. Decrease salt intake. Rationale: Reducing salt intake can help decrease fluid retention, minimizing swelling and discomfort during lactation suppression.

Answer 336

A. “Stimulation increases milk production and delays lactation suppression.” Rationale: Any breast stimulation, such as massage or sucking, increases milk production, which can prolong the lactation suppression process.

Answer 337

D. Upper outer quadrant Rationale: The upper outer quadrant of the breast is the most common site for mastitis due to the larger amount of breast tissue in this area.

Answer 338

C. “I should wean my baby immediately to help my breast heal.” Rationale: Weaning is not typically recommended with mastitis unless advised by a healthcare provider, as milk stasis may worsen the condition.

Answer 339

B. Fever and localized breast tenderness Rationale: Fever, localized tenderness, and redness are hallmark signs of mastitis. The condition does not typically involve urinary symptoms or headaches.

Answer 340

C. Pressure on the breast from a poorly fitting bra Rationale: A poorly fitting bra that exerts pressure on the breast can cause milk stasis, increasing the risk of mastitis.

Answer 341

A. Breast tenderness, redness, and flu-like symptoms Rationale: Mastitis presents with flu-like symptoms, redness, tenderness, and heat in the affected breast.

Answer 342

A. Encourage effective milk removal and administer prescribed antibiotics. Rationale: Effective milk removal and antibiotic therapy are critical components of mastitis treatment. Breast-feeding should continue unless contraindicated.

Answer 343

B. Ensure frequent and consistent breast-feeding sessions. Rationale: Frequent, consistent feeding prevents milk stasis, a major risk factor for mastitis. Cracked nipples should be treated, but breast-feeding is still encouraged with proper care.

Answer 344

B. Staphylococcus aureus Rationale: Staphylococcus aureus is the most common organism responsible for lactational mastitis, often originating from the infant’s mouth or throat.

Answer 345

C. Frequently skipping breast-feeding sessions Rationale: Infrequent or skipped feedings lead to milk stasis, a significant risk factor for mastitis. Consistent feeding and milk drainage reduce this risk.

Answer 346

C. Notify the healthcare provider for potential antibiotic therapy. Rationale: Mastitis often requires antibiotic therapy, effective milk removal, and pain management. Stopping breast-feeding is not recommended unless otherwise advised.

Answer 347

B. Reassure the client that continuing breast-feeding is safe and beneficial. Rationale: Continuing breast-feeding helps manage mastitis by promoting milk removal and is safe for both the mother and infant. Antibiotics should be started as prescribed, and abrupt weaning or fluid restriction is not recommended.

Answer 348

A. Encourage warm compresses before feedings to promote milk flow. Rationale: Warm compresses can promote milk flow, making feedings more comfortable and effective. Tight bras and decreased feeding frequency can worsen milk stasis and pain.

Answer 349

A. “Frequent nursing will help clear the infection and relieve symptoms.” Rationale: Frequent nursing or manual expression helps empty the breasts and prevent milk stasis, which is crucial in the treatment of mastitis.

Answer 350

C. “I will use ice packs only to reduce swelling and pain.” Rationale: Both ice packs and warm compresses can be used to manage pain and discomfort. Limiting to only ice packs may not provide optimal relief.

Answer 351

D. Encourage frequent nursing or manual expression to empty the breasts. Rationale: Frequent breast emptying through nursing or manual expression is essential to relieve milk stasis and promote recovery. Lactation suppression is not necessary, and both ice and warm packs may help with pain.

Answer 352

C. “I need to alternate breasts with each feeding and ensure proper latch.” Rationale: Alternating breasts and ensuring proper latch reduces the risk of milk stasis and nipple trauma, both of which can lead to mastitis. Soap should be avoided as it can dry the nipples, and tight bras can contribute to milk stasis.

Answer 353

A. Persistent fever despite antibiotic treatment. Rationale: Persistent fever despite antibiotics may indicate a breast abscess, which requires additional treatment, such as drainage.

Answer 354

D. “I’ll avoid touching or massaging the affected breast to reduce pain.” Rationale: Gentle massaging of the affected breast can help relieve milk stasis and prevent further complications. Avoiding breast contact may exacerbate milk stasis and worsen symptoms.

Answer 355

C. Notify the healthcare provider and anticipate starting antibiotics. Rationale: Flu-like symptoms, fever, and a tender, hot, red breast area are hallmark signs of mastitis. Prompt antibiotic treatment is necessary to prevent complications such as an abscess.

Answer 356

A. Teach the client proper latch techniques for breast-feeding. Rationale: Cracked skin can increase the risk of mastitis, often caused by poor latch techniques. Proper latch education is key to preventing further complications.

Answer 357

C. Flu-like symptoms such as malaise and body aches. Rationale: Flu-like symptoms, along with localized breast tenderness, redness, and swelling, are hallmark signs of mastitis and differentiate it from normal engorgement or other breast issues.

Answer 358

D. “Cesarean births pose no risk of infection to the client.” Rationale: Cesarean birth significantly increases the risk of infection due to the invasive nature of the procedure. Proper perioperative care is crucial to minimize this risk.

Answer 359

B. Transient tachypnea of the newborn. Rationale: Transient tachypnea of the newborn (TTN) is a common complication in neonates born via cesarean, as they do not experience the mechanical compression of the chest during vaginal delivery, which helps expel fluid from the lungs.

Answer 360

C. Sudden shortness of breath and chest pain. Rationale: Sudden shortness of breath and chest pain may indicate a pulmonary embolism, a serious complication following cesarean birth.

Answer 361

B. Dystocia. Rationale: Dystocia, or difficult labor, is one of the leading indications for cesarean delivery, along with previous cesarean birth, fetal distress, and breech presentation.

Answer 362

A. “Epidural anesthesia has fewer risks and allows you to remain awake for the birth experience.” Rationale: Epidural anesthesia is preferred for cesarean births because it poses fewer risks than general anesthesia and allows the mother to remain conscious during the birth.

Answer 363

A. Pulmonary embolism. Rationale: Cesarean birth is a major surgical procedure associated with risks such as infection, hemorrhage, pulmonary embolism, and thrombophlebitis.

Answer 364

A. A primigravida with a breech presentation. Rationale: Breech presentation is a leading indication for cesarean delivery, especially in a primigravida.

Answer 365

B. Use of electronic fetal monitoring. Rationale: The use of electronic fetal monitoring allows early identification of fetal distress, often leading to cesarean birth. Other contributors include increased maternal obesity, reduced forceps-assisted births, and convenience for providers.

Answer 366

C. “A previous cesarean birth guarantees I’ll have another one.” Rationale: While there is a high likelihood of a repeat cesarean after a primary cesarean, it is not guaranteed. Vaginal birth after cesarean (VBAC) may be an option depending on individual circumstances.

Answer 367

D. Fetopelvic disproportion. Rationale: Fetopelvic disproportion is a common cause of dystocia, as it prevents the fetus from safely passing through the birth canal.

Answer 368

C. Notify the provider for cesarean delivery orders. Rationale: Active genital herpes requires cesarean delivery to prevent neonatal infection with the herpes simplex virus.

Answer 369

C. “Certain malpresentations, such as breech, often require cesarean delivery.” Rationale: Certain malpresentations, like breech or transverse lie, often necessitate cesarean delivery to ensure maternal and fetal safety.

Answer 370

B. Previous classic uterine incision. Rationale: A previous classic uterine incision increases the risk of uterine rupture, making VBAC contraindicated.

Answer 371

A. Active genital herpes. Rationale: Active genital herpes during labor poses a significant risk of neonatal infection, necessitating cesarean delivery.

Answer 372

B. “This decision is entirely up to my provider.” Rationale: The decision for an elective cesarean birth should be made collaboratively, with the woman actively involved after receiving evidence-based counseling.

Answer 373

A. Fetal macrosomia. Rationale: Fetal macrosomia increases the risk of fetopelvic disproportion and complications during vaginal delivery, often necessitating a cesarean birth.

Answer 374

D. “Placenta previa means my baby’s placenta is covering my cervix.” Rationale: Placenta previa occurs when the placenta partially or completely covers the cervix, requiring cesarean delivery to prevent complications.

Answer 375

C. Ensuring the woman understands the procedure and feels supported. Rationale: The nurse’s primary focus should be on the client’s emotional and informational needs to ensure she feels supported and prepared for the procedure.

Answer 376

B. Using therapeutic communication and showing genuine care. Rationale: Therapeutic communication, touch, and genuine care help reduce anxiety and create a supportive environment, enhancing the client’s birth experience.

Answer 377

A. “Let me explain the procedure and answer any questions you have.” Rationale: Providing education and addressing the client’s questions helps alleviate anxiety by promoting understanding and involvement in her care.

Answer 378

C. Keeping the mother, partner, and newborn together whenever possible. Rationale: Family-centered care involves minimizing separation between the mother, partner, and newborn to support bonding and provide emotional comfort.

Answer 379

C. Blood type and cross-match Rationale: Blood type and cross-match are performed to ensure that compatible blood is available for transfusion if necessary during or after the cesarean birth.

Answer 380

A. Amniocentesis Rationale: Amniocentesis is performed to assess fetal lung maturity if there is a need to deliver the fetus before 39 weeks of gestation.

Answer 381

B. Administer preoperative medications as ordered and document the time and client’s reaction. Rationale: Administering preoperative medications as ordered and documenting the time and reaction is a key part of ensuring the client is prepared for surgery and that any medication response is properly documented.

Answer 382

D. To reduce pain and tension on the incision during coughing or movement Rationale: Splinting the incision helps reduce pain and tension during activities such as coughing or movement, which is crucial for comfort and recovery.

Answer 383

A. Instructing the client on the proper use of the incentive spirometer Rationale: Teaching the use of the incentive spirometer, deep breathing, and leg exercises are important preoperative measures to reduce postoperative complications such as atelectasis and thrombosis.

Answer 384

B. Preparing the surgical site as ordered. Rationale: Preparing the surgical site as ordered is a key preoperative task to ensure the area is sterile and ready for the surgery.

Answer 385

A. The client’s and family’s understanding of the procedure and expectations. Rationale: Assessing the client’s and family’s understanding of the procedure helps guide the teaching and emotional support process before surgery.

Answer 386

D. Offer detailed explanations to reduce anxiety and ensure understanding of the surgery. Rationale: Detailed explanations, including what to expect during and after the surgery, help reduce anxiety and promote understanding of the procedure.

Answer 387

D. Initiate the informed consent process as soon as possible Rationale: In an unplanned cesarean birth, ensuring the woman has signed the informed consent quickly and addressing her fears and expectations are crucial for the best outcomes.

Answer 388

A. Monitor vital signs and lochia flow every 15 minutes for the first hour. Rationale: In the immediate postoperative period, monitoring vital signs and lochia flow every 15 minutes for the first hour is essential for early identification of any complications such as hemorrhage.

Answer 389

B. Check the patency of the IV line and inspect for any other signs of infection. Rationale: Redness at the IV site may indicate infection or irritation. The nurse should check the IV line’s patency and inspect for further signs of complications, such as swelling or warmth, before making decisions.

Answer 390

B. Return of sensation to the legs. Rationale: After regional anesthesia, the nurse should monitor the return of sensation to the legs to ensure that the anesthesia is wearing off and to assess for any complications such as nerve injury or delayed sensation recovery.

Answer 391

D. Assist with early ambulation and encourage deep breathing exercises every 2 hours. Rationale: Early ambulation and frequent deep breathing exercises help prevent respiratory and cardiovascular complications, as well as promote peristalsis and venous return from the extremities.

Answer 392

A. Encourage the mother to use a side-lying position to minimize pressure on the incision site. Rationale: A side-lying position helps reduce pressure on the incision site, enhancing comfort while breastfeeding after a cesarean delivery.

Answer 393

D. Perform light activities, but avoid lifting for at least 6 weeks. Rationale: The nurse should encourage light activity, but advise the client to avoid lifting or strenuous activity for at least 6 weeks to promote healing and prevent complications like incisional hernia or strain.

Answer 394

B. Have the client void and then reassess the fundus. Rationale: A soft and displaced fundus may indicate bladder distention. The nurse should first have the client void to see if this resolves the issue before taking further action.

Answer 395

D. Perform a fundal check and assess the incision site for signs of bleeding. Rationale: Immediately after cesarean delivery, the nurse should first assess the fundus and incision site for bleeding to ensure the client’s immediate postoperative stability.

Answer 396

C. The client should request pain medication before pain becomes severe. Rationale: Early and proactive pain management is key to preventing the escalation of pain. The client should be encouraged to request pain medication before the pain becomes severe, which can help facilitate better recovery and mobilization.

Answer 397

A. To prevent the risk of aspiration during anesthesia. Rationale: NPO status is required to reduce the risk of aspiration during anesthesia. This is a safety precaution that helps prevent complications related to airway management during surgery.

Answer 398

B. Start an IV infusion for fluid replacement therapy as ordered. Rationale: Starting an IV infusion for fluid replacement therapy is essential for maintaining hydration and supporting the client’s circulatory needs during the procedure.

Answer 399

B. Assess the client’s level of consciousness and return of sensation from spinal anesthesia. Rationale: In the immediate postoperative period, assessing the return of sensation from spinal anesthesia is critical to ensure the client is fully alert and responsive before initiating ambulation or other activities.

Answer 400

D. Monitor for signs of uterine rupture in future pregnancies. Rationale: A classic uterine incision increases the risk of uterine rupture in future pregnancies. The nurse should educate the client about this risk and the need for careful monitoring during subsequent pregnancies.

Answer 401

D. Administering prophylactic antibiotics as ordered. Rationale: Prophylactic antibiotics are commonly administered to reduce the risk of infection during a cesarean delivery, regardless of the type of incision.

Answer 402

C. Notify the healthcare provider and prepare for an emergency cesarean birth. Rationale: Slow cervical dilation with signs of fetal distress in a woman attempting TOLAC may indicate complications such as uterine rupture. The priority is to notify the healthcare provider and prepare for a cesarean delivery to ensure the safety of both mother and baby.

Answer 403

B. “You are more likely to experience a cesarean birth again than to have a successful vaginal delivery.” Rationale: The risk of uterine rupture is higher during VBAC than in a first-time vaginal delivery, and the likelihood of a repeat cesarean is approximately 90% if a previous cesarean was performed.

Answer 404

B. Uterine rupture Rationale: Sudden severe abdominal pain, vaginal bleeding, and fetal heart rate decelerations are classic signs of uterine rupture. Immediate intervention is necessary to manage this life-threatening emergency.

Answer 405

D. Pitocin should be used only in low doses and with close monitoring. Rationale: Pitocin can be used in VBAC but must be administered at low doses with continuous monitoring to minimize the risk of uterine rupture.

Answer 406

A. Uterine rupture due to excessive contraction stimulation. Rationale: Uterine rupture is a significant concern during the second stage of labor in a woman with a previous cesarean delivery, especially if excessive contraction stimulation occurs or if labor is poorly monitored.

Answer 407

C. Monitor the fetal heart rate continuously and observe for signs of uterine rupture. Rationale: Continuous fetal heart rate monitoring is essential during TOLAC to detect signs of fetal distress or uterine rupture. Monitoring and close supervision are necessary for a safe labor and delivery.

Answer 408

C. Documentation of a low transverse uterine incision from the previous cesarean. Rationale: A low transverse uterine incision (Pfannenstiel incision) is required for VBAC eligibility. Classical or transverse incisions increase the risk of uterine rupture, making VBAC contraindicated.

Answer 409

A. Misoprostol Rationale: Misoprostol is contraindicated for cervical ripening in women attempting VBAC or TOLAC due to the increased risk of uterine rupture.

Answer 410

D. Continuous fetal monitoring and close supervision during labor. Rationale: Women undergoing TOLAC require continuous fetal monitoring and close supervision of labor to identify signs of uterine rupture or other complications, and allow for rapid intervention if a cesarean birth is needed.

Answer 411

D. Disruption of the uterine scar from the previous cesarean. Rationale: The primary risk of uterine rupture in VBAC is the disruption of the uterine scar from the previous cesarean, which can lead to serious maternal and fetal complications.

Answer 412

A. Blood pressure Rationale: Blood pressure is crucial to monitor closely as hypotension can indicate hypovolemic shock, a potentially life-threatening complication that may occur with uterine rupture.

Answer 413

B. Inform the woman of the seriousness of the situation Rationale: It is essential to inform the woman about the seriousness of the situation while providing reassurance. Clear communication helps manage anxiety and ensures the woman is aware of the steps being taken.

Answer 414

D. Prepare the operating room and alert the surgical team Rationale: The presence of hypotension and tachycardia suggests hypovolemic shock, which requires rapid intervention. Preparing the operating room and alerting the surgical team for an emergency cesarean is the priority action.

Answer 415

B. Prepare for an emergency cesarean delivery Rationale: In the case of uterine rupture, the most critical intervention is to prepare for an emergency cesarean delivery to ensure the health of both the mother and the fetus.

Answer 416

B. Prepare for an emergency cesarean delivery. Rationale: The absence of fetal heart tones, especially in the context of acute abdominal pain, raises suspicion for uterine rupture. The priority action is to prepare for an emergency cesarean delivery to address fetal distress and maternal complications.

Answer 417

A. Previous uterine myomectomy Rationale: A previous uterine myomectomy (removal of fibroids) can create scarring and increase the risk of uterine rupture during subsequent labor. This should be a key consideration during the assessment.

Answer 418

A. Continuous electronic fetal monitoring Rationale: Continuous electronic fetal monitoring is essential during TOLAC, as it provides real-time indications of fetal distress, which is often the first sign of uterine rupture.

Answer 419

C. History of placenta percreta Rationale: A history of placenta percreta significantly increases the risk of uterine rupture and should be prioritized when assessing risk. This condition leads to the abnormal attachment of the placenta to the uterine wall and can complicate labor and delivery.

Answer 420

A. Blood loss greater than 1,000 mL occurring within 24 hours of birth, with signs of hypovolemia Rationale: Primary postpartum hemorrhage is defined as blood loss greater than 1,000 mL within 24 hours of delivery, with signs of hypovolemia, which can lead to serious complications.

Answer 421

D. Anemia Rationale: Anemia is a common sequela of severe postpartum hemorrhage due to significant blood loss, leading to a decrease in hemoglobin and hematocrit levels.

Answer 422

A. A history of cesarean delivery Rationale: A history of cesarean delivery increases the risk for postpartum hemorrhage due to factors such as uterine scarring and possible complications during delivery.

Answer 423

B. Initiating fluid resuscitation and blood transfusions as needed Rationale: Initiating fluid resuscitation and blood transfusions promptly is critical to stabilize the patient and prevent complications such as shock, organ failure, and anemia.

Answer 424

C. Inadequate uterine contraction Rationale: The most common cause of postpartum hemorrhage is inadequate uterine contraction, which leads to uterine atony and excessive bleeding. This condition is preventable with proper management.

Answer 425

B. Monitor the mother for signs of hypovolemic shock Rationale: Monitoring for signs of hypovolemic shock is crucial to assess the severity of postpartum hemorrhage and guide timely intervention, such as fluid resuscitation and blood transfusion, as necessary.

Answer 426

C. Manual removal of the retained clots Rationale: Retained blood clots can prevent the uterus from contracting effectively and cause excessive bleeding. Manual removal of the clots may be necessary to stop the hemorrhage.

Answer 427

A. Previous uterine surgery Rationale: Previous uterine surgery, such as a cesarean section, increases the risk for uterine trauma, such as scarring or rupture, which can lead to postpartum hemorrhage.

Answer 428

B. Administer an oxytocin infusion Rationale: Oxytocin is a uterotonic medication that promotes uterine contractions, which are essential in preventing and controlling postpartum hemorrhage due to uterine atony.

Answer 429

C. Monitoring platelet levels closely Rationale: Idiopathic thrombocytopenia purpura (ITP) results in low platelet levels, increasing the risk of bleeding. Monitoring platelet levels closely and preparing for possible transfusion are key interventions to manage bleeding risk.

Answer 430

A. Polyhydramnios Rationale: Polyhydramnios (excessive amniotic fluid) causes uterine overdistention, increasing the risk for uterine muscle exhaustion and decreased uterine tone, which can lead to postpartum hemorrhage.

Answer 431

B. Prolonged rupture of membranes Rationale: Prolonged rupture of membranes increases the risk for infection and inflammatory response, which can trigger DIC, a coagulopathy that leads to widespread clotting and hemorrhage.

Answer 432

B. Lacerations of the genital tract

Answer 433

D. Avoid any forceful traction on the umbilical cord Rationale: Avoiding forceful traction on the umbilical cord is crucial in preventing uterine trauma, which could exacerbate bleeding, especially in patients with coagulation abnormalities such as von Willebrand disease.

Answer 434

D. Retained products of conception Rationale: An incomplete placenta at birth is considered a retained product of conception, which can lead to postpartum hemorrhage due to the continued presence of tissue in the uterus, preventing full uterine contraction.

Answer 435

A. Macrosomia Rationale: Macrosomia, or a larger-than-average baby, increases the risk of uterine overdistention, which can lead to uterine muscle exhaustion and poor contraction, increasing the risk for postpartum hemorrhage.

Answer 436

A. Uterine atony Rationale: Prolonged labor can lead to uterine muscle fatigue and uterine atony, which increases the risk of postpartum hemorrhage.

Answer 437

B. Hypotension, tachycardia, and decreased level of consciousness Rationale: Hypovolemic shock typically presents with hypotension, tachycardia, and decreased consciousness, which are signs of inadequate perfusion due to significant blood loss.

Answer 438

B. Severe perineal pain and a localized bulge in the perineum Rationale: Hematomas are associated with severe perineal pain and a localized bulge in the perineum, often requiring surgical intervention for evacuation.

Answer 439

B. Soft, boggy uterus with dark red bleeding Rationale: A soft, boggy uterus with dark red bleeding is a hallmark of uterine atony, the most common cause of early postpartum hemorrhage. Immediate intervention is needed to prevent further complications.

Answer 440

A. Hematoma Rationale: A hematoma in the perineal area, often seen with operative deliveries, presents as a bluish bulge and is associated with severe perineal pain, difficulty voiding, and signs of blood loss.

Answer 441

D. Severe blood loss leading to shock Rationale: Severe blood loss can lead to hypovolemic shock, which affects renal perfusion and results in acute renal failure. Monitoring kidney function and fluid balance is crucial in managing this complication.

Answer 442

B. Initiate intravenous fluid resuscitation Rationale: The priority intervention for hypovolemic shock is intravenous fluid resuscitation to restore blood volume and improve perfusion to vital organs, which is essential in stabilizing the patient.

Answer 443

B. Incision of the skin bulge to evacuate trapped blood Rationale: Hematomas may require surgical intervention, including incision of the skin bulge to evacuate trapped blood, especially if the patient is experiencing significant pain or difficulty voiding.

Answer 444

D. Lacerations of the genital tract Rationale: Bright red bleeding with a firm uterus often indicates trauma, such as lacerations of the genital tract. The absence of clots and firmness of the uterus differentiate this from uterine atony or retained placenta.

Answer 445

C. Massage the uterus to promote contraction Rationale: Uterine massage is the first-line intervention for uterine atony, as it helps stimulate uterine contractions and control bleeding. Immediate action can prevent further complications like hypovolemic shock.

Answer 446

A. Platelet count and prothrombin time (PT) Rationale: A platelet count and prothrombin time (PT) are key tests in diagnosing a coagulopathy, which could be the underlying cause of postpartum hemorrhage in a patient exhibiting signs like petechiae and oozing at venipuncture sites.

Answer 447

A. Soft, boggy uterus with dark red bleeding and clots Rationale: Retained placental fragments typically present with a soft, boggy uterus, dark red bleeding, and the presence of blood clots. A careful inspection of the placenta is necessary to confirm this diagnosis.

Answer 448

C. Place one hand over the symphysis pubis to anchor the uterus Rationale: Before performing manual fundal massage, it is essential to place one hand over the symphysis pubis to anchor the uterus, preventing uterine inversion during the procedure.

Answer 449

B. Being the first to recognize and respond to excessive blood loss Rationale: Nurses play a crucial role in the early recognition and response to excessive postpartum bleeding, ensuring prompt intervention and coordination of further treatments by the healthcare team.

Answer 450

A. Increased risk of renal failure, hepatic failure, and respiratory distress syndrome Rationale: Peripartum hysterectomy, a lifesaving procedure, carries significant risks, including renal failure, hepatic failure, respiratory distress syndrome, coagulopathies, septicemia, and tissue hypoxia.

Answer 451

A. Complete blood count (CBC), type and cross-match, and coagulation studies Rationale: A CBC, type and cross-match, and coagulation studies are critical to assess the patient’s blood volume and clotting status, ensuring compatibility and readiness for transfusion.

Answer 452

A. Begin intravenous fluid resuscitation and administer uterotonic agents Rationale: Once bleeding reaches 1,500 to 2,000 mL, intravenous fluid resuscitation and uterotonic medications should be initiated promptly to manage the bleeding.

Answer 453

D. Uterine compression sutures Rationale: Uterine compression sutures are a second-line treatment for uterine atony when initial interventions like fundal massage and uterotonic medications fail to control the bleeding.

Answer 454

D. Perform a fundal massage after anchoring the uterus Rationale: The priority intervention for uterine atony is fundal massage, which should be performed after anchoring the uterus with one hand over the symphysis pubis to prevent uterine inversion.

Answer 455

C. The medication may cause hypotension, so the nurse should monitor the patient’s blood pressure frequently. Rationale: Misoprostol can cause hypotension, and the nurse should monitor the patient’s blood pressure frequently during administration to prevent complications.

Answer 456

B. Monitoring uterine tone and vital signs every 15 minutes Rationale: The nurse must monitor uterine tone and vital signs every 15 minutes to assess the effectiveness of oxytocin and ensure the patient’s safety.

Answer 457

C. Chest pain Rationale: Chest pain should be promptly reported as it could indicate serious adverse effects such as myocardial ischemia or cardiovascular complications.

Answer 458

B. Nausea, vomiting, diarrhea, and flushing Rationale: Prostaglandin (PGF2α), carboprost (Hemabate) commonly causes nausea, vomiting, diarrhea, flushing, and bronchospasm, so the nurse should monitor for these symptoms.

Answer 459

B. Discontinue the methylergonovine maleate and report the finding Rationale: Methylergonovine maleate is contraindicated in patients with hypertension, and if the patient experiences elevated blood pressure, the medication should be discontinued and the healthcare provider notified.

Answer 460

A. Monitor the patient’s blood pressure frequently Rationale: Hypotension is a frequent side effect of dinoprostone, so the nurse should monitor blood pressure frequently during administration.

Answer 461

A. Active cardiovascular disease Rationale: Misoprostol is contraindicated in patients with active cardiovascular disease and should be used cautiously in those with asthma.

Answer 462

A. Monitor for signs of uterine hyperstimulation and assess uterine tone regularly Rationale: Oxytocin should be carefully monitored for uterine hyperstimulation, and uterine tone must be regularly assessed to ensure effective control of bleeding and to prevent adverse effects.

Answer 463

C. 30 minutes to 1 hour after insertion Rationale: The JADA system should be left in place for 30 minutes to 1 hour, after which it should be removed and the patient should be observed for any further bleeding.

Answer 464

A. Within 1 minute Rationale: Studies show that uterine collapse happens within 1 minute after the JADA system is placed, which helps control bleeding rapidly.

Answer 465

D. The JADA system is more expensive than the Bakri balloon Rationale: The JADA system is more expensive than the Bakri balloon, which may be a consideration for healthcare providers when choosing an appropriate intervention.

Answer 466

C. “The device will be left in place for several hours to monitor bleeding.” Rationale: The device should only be left in place for 30 minutes to 1 hour, not several hours. If the new nurse states otherwise, further teaching is necessary.

Answer 467

D. Observe the patient for further bleeding after removing the device Rationale: The device should be removed after 30 minutes to 1 hour, and the nurse should observe the patient for any further bleeding to assess the effectiveness of the intervention.

Answer 468

B. Observe for any further bleeding Rationale: After removal of the JADA system, it is essential to observe the patient for any further bleeding to ensure effective control and identify any complications.

Answer 469

C. “The device will be attached to wall suction to remove blood and maintain cervical seal.” Rationale: The JADA system is attached to wall suction to remove blood while maintaining the cervical seal, promoting uterine contraction and bleeding control.

Answer 470

C. It uses a low-level vacuum to promote natural uterine contraction Rationale: The JADA system uses a low-level vacuum to help the uterus contract naturally, offering a key advantage in controlling bleeding.

Answer 471

D. Place the device just past the internal os of the cervix Rationale: The JADA system is inserted just past the internal os of the cervix to help control bleeding and facilitate uterine contraction.

Answer 472

B. Inspect the placenta for completeness after expulsion Rationale: After expulsion, the placenta must be thoroughly inspected for completeness to rule out retained placental fragments, which could result in hemorrhage if not addressed.

Answer 473

C. Pain at the site of the hematoma and vital signs changes disproportionate to blood loss Rationale: Hematomas often present with pain at the site and changes in vital signs that are disproportionate to the amount of visible blood loss.

Answer 474

B. Uterine rupture Rationale: Women with a previous cesarean section are at higher risk for uterine rupture, especially during labor, due to the potential disruption of the uterine wall.

Answer 475

C. Cervical lacerations Rationale: Bright red blood trickling from the vagina with a contracted uterus is most often indicative of cervical lacerations, commonly associated with forceps deliveries.

Answer 476

B. Perform controlled delivery with gentle manipulation Rationale: Controlled delivery with gentle manipulation and appropriate inspection and repair of lacerations or episiotomy can help prevent trauma, such as lacerations and hematomas.

Answer 477

D. Neurological status for signs of clot formation Rationale: Clotting factor replacement therapy increases the risk of thrombosis, so the nurse should monitor neurological status for signs of clot formation, such as confusion or sudden weakness, which may indicate a thrombotic event.

Answer 478

A. Decreased fibrinogen levels and prolonged prothrombin time Rationale: In DIC, coagulation factors are consumed rapidly, leading to decreased fibrinogen levels, prolonged prothrombin time, and abnormal clotting tests. It can cause widespread bleeding and clotting problems.

Answer 479

B. Thrombotic thrombocytopenic purpura (TTP) Rationale: Thrombotic thrombocytopenic purpura (TTP) is a condition associated with a decreased platelet count, prolonged bleeding time, and fibrin degradation products. This can result in abnormal bleeding during the postpartum period.

Answer 480

D. Coagulation studies, including prothrombin time and fibrinogen levels Rationale: Coagulation studies are essential to diagnose coagulation disorders in postpartum hemorrhage. These studies include prothrombin time, fibrinogen levels, and other clotting factors that can confirm a bleeding disorder.

Answer 481

C. Observing for signs of bleeding despite normal uterine tone Rationale: Women with von Willebrand disease are at risk for bleeding disorders, and while uterine contractions are important, the nurse should be vigilant for signs of bleeding that may occur even with a well-contracted uterus.

Answer 482

D. Increased neonatal risk of scalp and facial trauma Rationale: One of the key disadvantages of vacuum extraction is the increased risk of neonatal trauma, including scalp lacerations and cephalohematoma.

Answer 483

B. Encouraging frequent ambulation and bladder emptying during labor Rationale: Encouraging ambulation and regular bladder emptying helps optimize pelvic space and positioning, potentially preventing the need for operative interventions like forceps or vacuum-assisted deliveries.

Answer 484

A. Apply gentle traction with the doctor to facilitate delivery Rationale: Gentle and steady traction is necessary during a vacuum-assisted delivery to guide the fetal head out while avoiding excessive force, which could lead to neonatal injury.

Answer 485

C. Increased head circumference and a palpable mass on the skull Rationale: Cephalohematoma is a collection of blood between the skull and the periosteum, often seen after a vacuum-assisted delivery. The head may show increased circumference and a palpable mass.

Answer 486

D. Both forceps and vacuum extractions are rare in current obstetric practice Rationale: The use of forceps and vacuum extractions has declined in modern obstetric practice, but they are still used when necessary, and their risks need to be carefully explained to the patient.

Answer 487

C. Higher success rate of delivery Rationale: Forceps have a lower failure rate compared to vacuum extraction, making them more reliable for assisting in deliveries when indicated. However, they do carry a higher risk for maternal pelvic floor injuries.

Answer 488

B. Lacerations of the cervix, vagina, or perineum Rationale: Maternal complications from forceps-assisted delivery include lacerations of the cervix, vagina, or perineum, as well as hematoma, hemorrhage, and infection.

Answer 489

B. Discontinue the procedure and prepare for a cesarean section Rationale: Fetal distress during a vacuum-assisted birth requires discontinuation of the procedure, reassessment, and possible preparation for cesarean delivery to ensure fetal safety.

Answer 490

A. Cephalohematoma Rationale: Vacuum-assisted deliveries can cause neonatal trauma, including cephalohematoma (a collection of blood between the skull and periosteum), which requires monitoring.

Answer 491

D. The membranes are ruptured and the cervix is completely dilated Rationale: For the vacuum extractor to be applied, the cervix must be fully dilated, the membranes ruptured, and the fetus engaged in the vertex position. These criteria ensure safe use of the instrument.

Answer 492

C) Administering oxytocin to strengthen contractions Rationale: Labor dystocia is characterized by abnormally slow or prolonged labor due to ineffective uterine contractions, fetal malposition, or cephalopelvic disproportion (CPD). If contractions are inadequate, oxytocin is often administered to improve labor progression. Fundal pressure is contraindicated, especially in cases of CPD, as it increases the risk of uterine rupture. Cesarean section may be necessary if labor does not progress despite interventions, but it is not the first-line response. McRoberts maneuver and suprapubic pressure are specific for shoulder dystocia, not labor dystocia.