Maternity

Question 1

A woman at 38 weeks’ gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding?

1. "I feel fine, but the bleeding scares me."
2. "I've been more nauseated during the past few weeks."
3. "The bleeding started after I carried four bags of groceries."
4. "I've been having severe abdominal cramps."

Answer 1

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Strategy: All answers are assessments. Think about what each phrase is describing and how it relates to a placenta previa.

(1) correct—placenta previa is characterized by painless vaginal bleeding
(2) nausea not a symptom of placenta previa
(3) bleeding is not necessarily related to activity
(4) pain not characteristic of placenta previa

Question 2

The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. Which of the following actions should the nurse take FIRST?

1. Withhold the medication.
2. Decrease the dose by half.
3. Administer the medication.
4. Wait 15 minutes, and then recheck the rate.

Answer 2

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Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? No. Determine the outcome of each answer choice.

(1) correct—maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure
(2) should never change a prescribed dosage of medication
(3) should not be given with a high pulse rate
(4) assessment; maternal tachycardia is a side effect of Brethine; medication should be withheld

Question 3

Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae?

1. Infection related to obstetrical trauma.
2. Potential for fetal injury related to abruptio placentae.
3. Potential alteration in tissue perfusion related to depletion of fibrinogen.
4. Fluid volume deficit related to bleeding.

Answer 3

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Strategy: Think about each answer choice.

(1) inaccurate for the situation
(2) incorrectly stated
(3) incorrectly stated
(4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients

Question 4

A client diagnosed with multiple sclerosis (MS) is at 39 weeks’ gestation. The client is admitted to the labor and delivery unit in active labor. The client’s vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following?

1. Prepare to administer IV Pitocin to the client.
2. A reduction in the amount of pain medication administered.
3. Check the client's blood pressure every 5 minutes.
4. Prepare an isolette for the infant.

Answer 4

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Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention.

(1) uterine contractions not affected by MS
(2) correct—less pain medication is required because of overall decrease in pain perception due to MS
(3) no reason to assess this frequently
(4) baby’s outcome not affected by MS

Question 5

The nurse cares for clients in the antepartal clinic. A client at 34 weeks’ gestation comes to the clinic for treatment of a sprained ankle. The nurse should question which of the following orders?

1. ASA (aspirin) 650 mg PO q4h prn for pain.
2. Return to the clinic in 2 weeks.
3. Apply ice to sprain for 20 minutes qh for 24 hours.
4. Teach client three-gait crutch walking.

Answer 5

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Strategy: Determine the outcome of each answer choice. Is it desired?

(1) correct—aspirin can cause fetal hemorrhage; do not use during pregnancy
(2) routine follow-up
(3) treat sprain with rest and elevation of affected part; intermittent ice compresses for 24 hours
(4) appropriate gait if client unable to bear weight

Question 6

Which of the following nursing actions is important for safe administration of oxytocin?

1. Assess respirations and urine output.
2. Administer oxytocin parenterally as the primary IV.
3. Have calcium gluconate available as an antidote.
4. Palpate the uterus frequently.

Answer 6

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Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? Yes.

(1) assessment; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia
(2) implementation; oxytocin is always given via an infusion pump and is never allowed to be the primary IV
(3) implementation; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia
(4) correct—assessment; oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus

Question 7

The nurse observes late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. Which of the following actions should the nurse take FIRST?

1. Discontinue the infusion.
2. Turn client to the left side.
3. Change the fluids to Ringers lactate.
4. Increase the IV flow rate.

Answer 7

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
(2) may help the deceleration, but is not a priority
(3) will have no influence on the fetal heart rate
(4) will have no influence on the fetal heart rate

Question 8

The nurse cares for an 8-lb, 8-oz newborn. The infant’s history indicates the mother was given magnesium sulfate IV 4 g in 250 mL D5W several hours before delivery. The nurse is MOST concerned if which of the following was observed?

1. Temperature 97.6°F (36.5°C).
2. Apical pulse 140 bpm.
3. Respirations 18/min.
4. BP 80/50.

Answer 8

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Strategy: “MOST concerned” indicates a complication.

(1) normal temperature 98.6°F (37.0°C), magnesium sulfate does not affect temperature
(2) normal pulse 120-140 bpm, magnesium sulfate does not affect cardiac system of infant
(3) correct—magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
(4) normal BP 60/40-80/50, magnesium sulfate does not affect BP

Question 9

The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33 weeks’ gestation. Based on this result, the nurse anticipates which of the following?

1. Administration of ritodrine hydrochloride (Yutopar).
2. Initiation of an oxytocin (Pitocin) drip.
3. Delivery of the infant by cesarean section.
4. Continuation of bedrest until otherwise indicated.

Answer 9

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Strategy: Determine the significance of each answer choice and how it relates to the L/S ratio.

(1) no longer necessary, as the results indicate sufficient lung maturity for safe delivery
(2) although the lungs are mature enough for safe delivery, client would either be allowed to progress naturally to a vaginal delivery or would be sectioned, but not induced
(3) correct—because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
(4) is no longer necessary with adequately mature lungs

Question 10

for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?

1. The client complains of epigastric pain.
2. The client complains of shortness of breath.
3. The client states she has increased rectal pressure.
4. The client has gained of 33 pounds during her pregnancy.

Answer 10

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Strategy: Think about the cause of each symptom and how it relates to pregnancy.

(1) correct—is usually indicative of an impending convulsion
(2) expected observation
(3) expected observation
(4) is important to address, but is not as high a priority as answer choice 1

Question 11

Prior to a caesarean section delivery, a client is treated for abruptio placenta. The nurse cares for the woman during the postpartum period. Which of the following symptoms is suggestive of disseminated intravascular coagulation (DIC)?

1. The client's vital signs are: BP 90/58, temperature 101.0°F (38.3°C), pulse 112/min, respirations 18/min.
2. The client’s laboratory results are Hgb 13 g/dL, HCT 40%, WBC 7,000/ mm3.
3. The client is nauseated, lethargic, and has vomited three times.
4. There is oozing blood from the venipuncture site and abdominal incision.

Answer 11

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Strategy: Determine how each answer choice relates to DIC.

(1) may indicate hemorrhage or sepsis
(2) results normal, DIC would be reflected in clotting studies (PT, PTT)
(3) nonspecific, could be related to anesthesia or pain medication
(4) correct—DIC is an acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom

Question 12

A 20-year-old primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse should encourage the women to do which of the following?

1. Apply moisturizer to the breasts every day after bathing.
2. Expose the breasts to air every day for 20 minutes.
3. Wash breasts with water and rub with a towel every day.
4. Massage the breasts to increase circulation twice daily.

Answer 12

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) use of creams not recommended, could cause breast tissues to become tender, sebaceous glands keep skin pliable
(2) doesn’t prepare breasts for feeding
(3) correct—prepares nipples for stretching action of sucking during breast feeding, soap avoided to prevent drying
(4) could cause breast tissues to become tender

Question 13

The nurse makes rounds on the postpartum unit. The nurse notes that a client’s uterus is relaxed. The nurse should take which of the following actions?

1. Put the infant to the woman's breast.
2. Encourage the woman to drink warm oral fluids.
3. Check the woman's pulse and respirations.
4. Continue to monitor the firmness of the uterus.

Answer 13

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Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation.

(1) correct—implementation, causes natural surge of oxytocin that results in contraction of uterus
(2) implementation, has no effect on contraction of uterus
(3) assessment, not best action, situation does not suggest that patient is in shock
(4) assessment, needs manual massage or release of natural oxytocin to contract uterus

Question 14

The nurse enters the room of a 17-year-old mother breast feeding her 6-lb, 7-oz infant girl. Which of the following observations, if made by the nurse, BEST indicates that mother-infant bonding is taking place successfully?

1. The mother is looking into her infant's eyes as she feeds her.
2. The mother and infant are laying side-by-side in the bed.
3. The mother appears to be relaxed and is reading a book on childcare.
4. The mother interrupts feeding the infant to talk to her roommate.

Answer 14

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Strategy: Determine how each answer choice relates to bonding.

(1) correct—shows bonding behavior of eye-to-eye contact, proceeds to touching and holding
(2) shows distance between mother and infant
(3) doesn’t involve communication between mother and infant
(4) shows distance between mother and infant

Question 15

The nurse reviews histories in the prenatal clinic. The nurse identifies which of the following pregnant women is MOST likely to have an Rh-incompatibility problem?

1. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man. The woman has never received RhoGAM.
2. An Rh-negative woman who conceived with an Rh-positive man. The woman has Rh antibodies.
3. An Rh-positive woman who previously aborted a fetus at 12 weeks’ gestation and did not receive RhoGAM. The woman currently conceived with an Rh-positive man.
4. An Rh-negative woman who never received RhoGAM. The woman currently conceived with an Rh-negative man.

Answer 15

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Strategy: Think about each answer choice.

(1) incompatibility only seen with Rh-negative woman
(2) correct—Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus’s blood cells
(3) incompatibility only seen with Rh-negative woman
(4) infant would be Rh-negative like parents, so there would be no incompatibility

Question 16

The nurse plans care for a client immediately after a cesarean section. Which of the following nursing goals is MOST important?

1. Prevent infection.
2. Prevent fluid and electrolyte imbalances.
3. Provide for pain management.
4. Prevent hazards of immobility.

Answer 16

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Strategy: “MOST important” indicates that this is a priority question. Remember the ABCs.

(1) not highest priority initially, usually not seen until 48-72 hours after surgery
(2) correct—hemorrhage and shock are the most life-threatening conditions that occur after surgery
(3) not highest priority initially, not life-threatening
(4) not highest priority initially, not life-threatening

Question 17

A client is admitted with a diagnosis of a fractured right hip. The doctor writes an order for Buck’s traction. Which of the following actions, if taken by the nurse, is MOST important?

1. Turn the client every 2 hours to the unaffected side.
2. Maintain the client in a supine position.
3. Encourage the client to use a bedside commode.
4. Place a footboard on the bed.

Answer 17

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—immobility is a leading cause of problems with Buck’s traction; important to turn client to unaffected side
(2) head of the bed should be elevated 15-20° because the supine position can increase problems with immobility
(3) client is on strict bedrest
(4) would interfere with the traction

Question 18

The nurse monitors a client in active labor who is receiving oxytocin (Pitocin) 1 mU/min IV. The nurse should stop the infusion if which of the following is observed?

1. The contractions occur at 3-minute intervals and last more than 60 seconds.
2. The contractions occur at 2.5-minute intervals and last more than 90 seconds.
3. The contractions occur at 2-minute intervals and last more than 90 seconds.
4. The contractions occur at 2-minute intervals and last more than 60 seconds.

Answer 18

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Strategy: All answers are assessments. Determine the result of each assessment.

(1) normal frequency and duration
(2) normal frequency and duration
(3) correct—contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds); allows for longer resting time between contractions
(4) normal frequency and duration

Question 19

A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou smear. The nurse should recommend which of the following to the client?

1. Avoid intercourse for 48 hours before the examination.
2. Avoid douching for 24 hours before her appointment.
3. Withhold all foods and fluids 12 hours before the appointment.
4. Save her first voided urine specimen the morning of her appointment.

Answer 19

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Strategy: All answers are implementations. Think about the outcome of each answer choice. Is it desired?

(1) sperm doesn’t resemble atypical cells that the test is designed to find
(2) correct—douching would affect appearance of cells in vaginal smear, would make test inaccurate
(3) will concentrate urine but won’t affect Pap smear
(4) part of routine GYN exam, but not related to Pap smear

Question 20

The nurse is caring for a woman completing the first stage of labor. The woman’s husband is at her side and has been coaching her according to exercises they learned in childbirth classes. Suddenly the woman begins to shake and screams, “I can’t stand this anymore!” The nurse should encourage the husband to take which of the following actions?

1. Instruct his wife to use shallow respirations during the contractions.
2. Offer his wife ice chips or sips of water to distract her from the pain.
3. Stroke his wife's abdomen between contractions.
4. Review with his wife the breathing pattern needed at each stage of labor.

Answer 20

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Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
(2) doesn’t address issue of breathing pattern needed during transition phase of labor
(3) used in conjunction with controlled breathing for Lamaze
(4) needs support and coaching of husband during transition phase of labor