Midterm Study Questions Flashcards
One of the assessments performed in the birth room is checking the umbilical cord for blood vessels. Which finding is considered to be within normal limits?
A. One artery and one vein
B. Two veins and one artery
C. Two arteries and one vein
D. Two arteries and two veins
C. Two arteries and one vein
A nurse on a labor unit is caring for a patient who just received an epidural. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
A) Notify the provider of the findings.
B) Position the client on her side.
C) Ask the client if she is still in pain.
D) Have the client void.
B) Position the client on her side.
A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus?
A. Calcium
B. Iron
C. Vitamin C
D. Folic acid
D. Folic acid
A nurse in a prenatal clinic is caring for a client who is at 38 weeks gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make?
A. There is no evidence of cervical incompetence.
B. There is no evidence of two or more accelerations in fetal heart rate in 20 min.
C. There is no evidence of uteroplacental insufficiency.
D. There are less than 3 uterine contractions in a 10 min period.
C. There is no evidence of uteroplacental insufficiency.
Sign of ectopic pregnancy
Lower sharp abdominal pain on one side (unilateral)
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
A. The fetal head is in the left occiput posterior position.
B. The largest fetal diameter has passed through the pelvic outlet.
C. The posterior fontanel is palpable.
D. The lowermost portion of the fetus is at the level of the ischial spines.
D. The lowermost portion of the fetus is at the level of the ischial spines.
Rationale: The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.
Last menstrual period: June 4. Estimated delivery day?
March 11
After the start of contraction, fetal heart rate starts decreasing what is your intervention
reposition on lateral side
If not an option choose oxygen
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?
A. The presenting part is 1cm above the ischial spines.
B. The presenting art is 1cm below the ischial spines.
C. The cervix is 1cm dilated.
D. The cervix is effaced 1cm.
A. The presenting part is 1cm above the ischial spines.
Rationale: Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus 1, then the presenting part is 1cm above the ischial spines.
A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients?
A. A client who has mitral valve prolapse
B. A client who has been exposed to AIDS
C. All of the clients
D. A client who has a history of preterm labor.
C. All of the clients
Rationale: MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.
End of NST, 30 mins, baseline 140, minimal variability, no accelerations, 2 decel. Is this a reactive or non-reactive test.
Non-reactive
Rationale: Indicates the absence of these accelerations and could suggest fetal distress or other issues requiring further evaluation.
A reactive NST Requires two or more accelerations of the fetal heart rate of at least 15 beats per minute above the baseline, lasting at least 15 seconds, within a 20-minute period.
A nurse in a clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?
A. Decreased vaginal discharge
B. A surge of energy
C. Urinary retention
D. Weight gain of 0.5 to 1.5 kg
B. A surge of energy
Rationale: Prior to the onset of labor, the pregnant client experiences a surge of energy.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
A. Vomiting
B. Tachycardia
C. Respiratory depression
D. Hypotension
D. Hypotension
Rationale: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a durtiong of 1min and a frequency of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54mmHg. Which of the following is the priority action for the nurse to take?
A. Notify the provider of the findings.
B. Position the client with one hip elevated.
C. Ask the client if she needs pain medication.
D. Have the client void.
B. Position the client with one hip elevated.
Rationale: Based on Maslow’s hierarchy of needs, the client’s need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.
A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness?
a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
d. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.
b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
Rationale: Dehydration and electrolyte imbalances result from persistent nausea and vomiting associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta.
Recommend rubella immunizations
AFTER delivery
A nurse is caring for a client who is at 36 weeks of gestation and who has suspected placenta previa. Which of the following findings support this diagnosis?
a. Painless red vaginal bleeding
b. Increasing abdominal pain with a non relaxed uterus
c. Abdominal pain with scant red vaginal bleeding
d. Intermittent abdominal pain following passage of bloody mucus
a. Painless red vaginal bleeding
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity to magnesium sulfate therapy and report to the provider?
A. Respiratory depression
B. Facial flushing
C. Nausea
D. Drowsiness
A. Respiratory depression
Magnesium sulfate toxicity can cause life-threatening adverse effects, including respiratory and CNS depression. The nurse should report a respiratory rate slower than 12/min immediately to the provider and stop the infusion.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
A. Temperature
B. Fetal heart rate (FHR)
C. Bowel sounds
D. Respiratory rate
D. Respiratory rate
Reason to do maternal serum alpha-fetoprotein
Ror spinal, neural, and abdominal wall defects.
Ex: spina bífida and anencephaly
Omphalocele and gastroschisis
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client’s newborn at risk for which of the following complications?
A. Hearing loss
B. Intrauterine growth restriction
C. Type 1 diabetes mellitus
D. Congenital heart defects
B. Intrauterine growth restriction
Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death.
Nurse is caring for patient who’s pregnant and at end of her 1st trimester. Nurse should place Doppler ultrasound stethoscope in which locations to begin assessing fetal heart tones (FHT)?
A. Just above the umbilicus
B. Just above the symphysis pubis
C. The right lower quadrant
D. The left lower quadrant
Just above the symphysis pubis
At the end of the first trimester of pregnancy, the client’s uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
A. Cocaine use
B. Hypertension
C. Blunt force trauma
D. Cigarette smoking
B. Hypertension
Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
A. Administer prescribed analgesic medication
B. Encourage the client to rest between contractions
C. Massage the client’s back
D. Turn the client onto her left side
C. Massage the client’s back
The Gate Control Theory of Pain suggests that pain perception is modulated by a “gate” mechanism in the spinal cord that can either enhance or inhibit pain signals before they reach the brain.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?
A. Apply sacral counterpressure
B. Perform transcutaneous electrical nerve stimulation (TENS)
C. Initiate slow-paced breathing.
D. Assist with biofeedback
A. Apply sacral counterpressure
Applying sacral counterpressure can help alleviate back pain during contractions.
Pt comes in HA, spots in eyes, BP 150/90 u will
Administer an antihypertensive(to lower BP)
Mag sulfate(to prevent seizures)
Check protein in urine
Pt comes in and has vaginal spotting, RLQ pain what are we suspecting
Ectopic pregnancy
Meds to give?? Methotrexate
A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15weeks of gestation. Which of the following should be included in the teaching?
A. “The test will be performed if your baby’s heart beat is heard.”
B. “This test will determine if your baby’s lungs are mature.”
C. “This test requires the presence of amniotic fluid.”
D. “After the test, you will be given Rh0 immune globulin since you are Rh positive.”
C. “This test requires the presence of amniotic fluid.”
Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation.
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?
A. Apply a fetal scalp electrode.
B. Increase the rate of the IV infusion. Rationale:
C. Administer oxygen at 10 L/min via a nonrebreather mask.
D. Change the client’s position.
D. Change the client’s position.
The first action the nurse should take is to change the client’s position in an attempt to increase blood flow to the fetus.
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which reason?
A. The client’s blood does not contain the Rh factor, so she produces antiRh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns
B. The client’s blood contains the Rh factor and the newborn’s does not, antibodies that destroy red blood cells are formed in the fetus
C. The client has a history of receiving a transfusion with Rh-negative blood
D. The client’s blood is Rh-positive and therefore forms antibodies against the fetus’Rh-negative blood which cross the placenta and causes the destruction of the fetal red blood cells
A. The client’s blood does not contain the Rh factor, so she produces antiRh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns
