TEST 3: The Birth Experience

Question 1

The Primigravid Client in Labor
1. The nurse is managing care of a primigravida at full term who is in active labor. What should
be included in developing the plan of care for this client?
1. Oxygen saturation monitoring every half hour.
2. Supine positioning on back, if it is comfortable.
3. Anesthesia/pain level assessment every 30 minutes.
4. Vaginal bleeding, rupture of membrane (ROM) assessment every shift.

Answer 1

The Primigravid Client in Labor
1. 3. The nurse should monitor anesthesia/pain levels every 30 minutes during active labor to
ascertain that this client is comfortable during the labor process and particularly during active labor
when pain often accelerates for the client. When in active labor, oxygen saturation is not monitored
unless there is a specific need, such as heart disease. The client should not be on her back but wedged
to the right or left side to take the pressure off the vena cava. When lying on the back, the fetus
compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30
minutes to 1 hour.
CN: Reduction of risk potential; CL: Create

Question 2

2. The primary health care provider prescribes intermittent fetal heart rate monitoring for a 20-
   year-old obese primigravid client at 40 weeks’ gestation in the first stage of labor. The nurse should
   monitor the client’s fetal heart rate pattern at which of the following intervals?
3. Every 15 minutes during the latent phase.
4. Every 30 minutes during the active phase.
5. Every 60 minutes during the initial phase.
6. Every 2 hours during the transition phase.

Answer 2

2. 2. Labor is categorized into three phases: latent, active, and transition. During the active stage
      of labor, intermittent fetal monitoring is performed every 30 minutes to detect changes in fetal heart
      rate such as bradycardia, tachycardia, or decelerations. If complications develop, more frequent or
      continuous electronic fetal monitoring may be needed. During the latent phase, intermittent monitoring
      is usually performed every 2 hours because contractions during this time are usually less frequent.
      During the transition phase, intermittent monitoring is performed every 5 to 15 minutes because the
      client is getting closer to birth of the baby. There is no initial phase of labor.
      CN: Reduction of risk potential; CL: Analyze

Question 3

3. Assessment reveals that the fetus of a multigravid client is at +1 station and 8 cm dilated.
   Based on these data, the nurse should first:
4. Ask the anesthesiologist to increase epidural infusion rate.
5. Assist the client to push if she feels the need to do so.
6. Encourage the client to breathe through the urge to push.
7. Support family members in providing comfort measures.

Answer 3

3. 3. The urge to push is often present when the fetus reaches + stations. This client does not have
      a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the
      client to breathe through the urge to push is the most appropriate strategy and allows the cervix to
      dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to
      have the client be able to push when she is fully dilated. This may occur quickly with a multigravid
      client. Comfort measures are important for the client at this time, but are not the highest priority for
      the nurse.
      CN: Management of care; CL: Synthesize

Question 4

4. Assessment of a primigravid client in active labor who has had no analgesia or anesthesia
   reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should
   expect the client to exhibit which of the following behaviors during this phase of labor?
5. Excitement.
6. Loss of control.
7. Numbness of the legs.
8. Feelings of relief.

Answer 4

4. 2. Assessment findings indicate that the client is in the transition phase of labor. During this
      phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea,
      vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase
      of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is
      rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the
      client begins bearing-down efforts.
      CN: Health promotion and maintenance; CL: Analyze

Question 5

5. The nurse is explaining to a primigravida in labor that her baby is in a breech presentation,
   with the baby’s presenting part in a left, sacrum, posterior (LSP) position. Which illustration should
   the nurse use to help the client understand how her baby is positioned?
   1.
   2.3.
   4.

Answer 5

5. 1. This figure shows the client’s baby in a breech presentation with the baby facing the pelvis
      on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the
      pelvis. Figure 2 shows a vertex presentation with the baby in a left, occiput, anterior position (LOA).
      Figure 3 shows a vertex presentation, left, occiput, posterior (LOP). Figure 4 shows a face position
      with the baby in a left, mentum, transverse position (LMT).
      CN: Physiological adaptation; CL: Synthesize

Question 6

6. While caring for a moderately obese primigravid client in active labor at term, the nurse
   should monitor the client for signs of which of the following?
7. Hypotonic reflexes.
8. Increased uterine resting tone.
9. Soft tissue dystocia.
10. Increased fear and anxiety.

Answer 6

6. 3. The obese pregnant client is more susceptible to soft tissue dystocia, which can impede the
      progress of labor. Symptoms of soft tissue dystocia would include an arrest of labor, prolonged labor,
      or an arrest of descent of the fetus. Hypotonic reflexes are associated with magnesium sulfate therapy,
      and increased uterine resting tone is associated with hypertonic labor patterns in early labor, not with
      obesity and pregnancy. Increased fear and anxiety are also not associated with obesity. However, they
      may be associated with a primigravid client who does not know what to expect during labor.
      CN: Reduction of risk potential; CL: Analyze

Question 7

7. The nurse is caring for a primigravid client in active labor at 42 weeks’ gestation. The client
   has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to
   this client by:
8. Changing her pushing position every 15 minutes.
9. Notifying the health care provider of her current status.
10. Continuing with current pushing technique.
11. Assessing the client’s current pain and fetal status.

Answer 7

7. 2. The normal length of time for pushing is 2 hours. Anything over that time becomes an
      abnormal situation and the health care provider needs to be notified. Changing the client’s position is
      an appropriate nursing action within the 2-hour time period based on client need and fetal descent.
      Continuing current pushing supports techniques that have not been successful within the 2-hour time
      frame. Assessing client pain and fetal status are standards of care for laboring clients, but will not
      expedite childbirth for a client who has been pushing this long.
      CN: Safety and infection control; CL: Synthesize

Question 8

8. The primary health care provider has prescribed prostaglandin gel to be administeredvaginally to a newly admitted primigravid client. Which of the following indicate that the client has
   had a therapeutic response to the medication?
9. Resting period of 2 minutes between contractions.
10. Normal patellar and elbow reflexes for the past 2 hours.
11. Softening of the cervix and beginning of effacement.
12. Leaking of clear amniotic fluid in small amounts.

Answer 8

8. 3. Prostaglandin gel may be used for cervical ripening before the induction of labor with
      oxytocin. It is usually administered by catheter or suppository, or by vaginal insertion. Two to three
      doses are usually needed to begin the softening process. Common adverse effects include nausea,
      vomiting, fever, and diarrhea. Continuous fetal heart rate monitoring and close monitoring of maternal
      vital signs are necessary to detect subtle changes or adverse effects. Prostaglandin gel usually does
      not initiate contractions; therefore, the rest period between contractions will be >2 minutes. There is
      no need to assess reflexes based on prostaglandin use. Leaking of amniotic fluid is not caused by the
      use of this gel.CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 9

9. A primigravid client is admitted as an outpatient for an external cephalic version. The nurse
   should assess the client for which of the following contraindications for the procedure?
10. Multiple gestation.
11. Breech presentation.
12. Maternal Rh-negative blood type.
13. History of gestational diabetes.

Answer 9

9. 1. External cephalic version is the turning of the fetus from a breech position to the vertex
      position to prevent the need for a cesarean birth. Gentle pressure is used to rotate the fetus in a
      forward direction to a cephalic lie. Contraindications to the procedure include multiple gestation
      because of the potential for fetal injury or uterine injury, severe oligohydramnios (decreased amniotic
      fluid), contraindications to a vaginal birth (eg, cephalopelvic disproportion), and unexplained third
      trimester bleeding. If the mother has Rh-negative blood type, the procedure can be performed and Rh
      immunoglobulin should be administered in case minimal bleeding occurs. A history of gestational
      diabetes is not a contraindication unless the fetus is large for gestational age and the client has
      cephalopelvic disproportion.
      CN: Reduction of risk potential; CL: Analyze

Question 10

10. A primigravida is admitted to the labor area with ruptured membranes and contractions
    occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client’s contractions are
    now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. The
    expected outcome of this drug is:
11. The cervix will begin to dilate 2 cm/h.
12. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity,
    resting tone between contractions.
13. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to
    anterior position.
14. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70
    mm Hg.

Answer 10

10. 2. The goal of oxytocin administration in labor augmentation is to establish an adequate
       contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions
       occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a palpable resting
       tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or
       too slowly. Cervical changes in softening, effacement, and moving to an anterior position are
       associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 cm/h
       is too rapid for the induction/augmentation process.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 11

11. A primigravid client in the second stage of labor feels the urge to push. The client has had no
    analgesia or anesthesia. Anatomically, which of the following would be the best position for the
    client to assume?
12. Dorsal recumbent.
13. Lithotomy.
14. Hands and knees.
15. Squatting.

Answer 11

11. 4. Anatomically, the best position for the client to assume is the squatting position because this
       enhances pelvic diameters and allows gravity to assist in the expulsion stage of labor. This position
       also provides for natural pressure anesthesia as the fetal presenting part presses on the stretched
       perineum. If the client is extremely fatigued from a lengthy labor process, she may prefer the dorsal
       recumbent position. However, this position is not considered the best position anatomically. The
       lithotomy position may be ineffective and uncomfortable for a client who is ready to push. The hands
       and knees position may help to alleviate some back pain. However, this position can cause
       discomfort to the arms and wrists and is tiring over a long period of time.
       CN: Health promotion and maintenance; CL: Apply

Question 12

12. A 21-year-old primigravid client at 40 weeks’ gestation is admitted to the hospital in active
    labor. The client’s cervix is 8 cm and completely effaced at 0 station. During the transition phase of
    labor, which of the following is a priority nursing problem?
13. Urinary retention
14. Hyperventilation
15. Ineffective coping
16. Pain

Answer 12

12. 4. During transition, contractions are increasing in frequency, duration, and intensity. The most
       appropriate nursing problem is pain related to strength and duration of the contractions. Insufficient
       information is provided in the scenario to support the other listed nursing diagnoses. Urinary retention
       would be appropriate if the client had a full bladder and was unable to void. Hyperventilation might
       apply if client was breathing too rapidly, but there is no evidence this is occurring. Ineffective coping
       might apply if the client said, “I can’t do this” or something similar.
       CN: Health promotion and maintenance; CL: Analyze

Question 13

13. A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to
    receive oxytocin intravenously after delivery of the placenta. Which of the following signs would
    indicate to the nurse that the placenta is about to be delivered?
14. The cord lengthens outside the vagina.
15. There is decreased vaginal bleeding.
16. The uterus cannot be palpated.4. Uterus changes to discoid shape.

Answer 13

13. 1. The most reliable sign that the placenta has detached from the uterine wall is lengthening of
       the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal
       blood. Usually, when placenta detachment occurs, the uterus becomes more firm and changes in shape
       from discoid to globular. This process takes about 5 minutes. If the placenta does not separate,
       manual removal may be necessary to prevent postpartum hemorrhage.
       CN: Health promotion and maintenance; CL: Analyze

Question 14

14. A primiparous client, who has just given birth to a healthy term neonate after 12 hours of
    labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of
    which of the following?
15. Disappointment in the baby’s gender.
16. Grief over the ending of the pregnancy.
17. A normal response to the birth.
18. Indication of postpartum “blues.”

Answer 14

14. 3. Childbirth is a very emotional experience. An expression of happiness with tears is a
       normal reaction. Cultural factors, exhaustion, and anxieties over the new role can all affect maternal
       responses, so the nurse must be sensitive to the client’s emotional expressions. There is no evidence
       to suggest that the mother is disappointed in the baby’s gender, grieving over the end of the pregnancy,
       or a candidate for postpartum “blues.” However, approximately 80% of postpartum clients
       experience transient postpartum blues several days after childbirth.
       CN: Health promotion and maintenance; CL: Analyze

Question 15

15. The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and
    50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which
    of the following should the nurse recommend at this time?
16. Resting in the right lateral recumbent position.
17. Lying in the left lateral recumbent position.
18. Walking around in the hallway.
19. Sitting in a comfortable chair for a period of time.

Answer 15

15. 3. Most authorities suggest that a woman in an early stage of labor should be allowed to walk
       if she wishes as long as no complications are present. Birthing centers and single-room maternity
       units allow women considerable latitude without much supervision at this stage of labor. Gravity and
       walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed
       in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent
       position improves circulation to the fetus.
       CN: Health promotion and maintenance; CL: Synthesize

Question 16

16. Which of the following would the nurse include in the teaching plan for a 16-year-old
    primigravid client in early labor concerning active relaxation techniques to help her cope with pain?
17. Relaxing uninvolved body muscles during uterine contractions.
18. Practicing being in a deep, meditative, sleeplike state.
19. Focusing on an object in the room during the contractions.
20. Breathing rapidly and deeply between contractions.

Answer 16

16. 1. Childbirth educators use various techniques and methods to prepare parents for labor and
       birth. Active relaxation involves relaxing uninvolved muscle groups while contracting a specific
       group and using chest breathing techniques to lift the diaphragm off the contracting uterus. A deep,
       meditative, sleeplike state is a form of passive relaxation. Focusing on an object in the room is part of
       Lamaze technique for distraction. Breathing rapidly and deeply can lead to hyperventilation and is not
       recommended.
       CN: Health promotion and maintenance; CL: Synthesize

Question 17

17. The nurse is performing effleurage for a primigravid client in early labor. The nurse should
do which of the following?
1. Deep kneading of superficial muscles.
2. Secure grasping of muscular tissues.
3. Light stroking of the skin surface.
4. Prolonged pressure on specific sites.

Answer 17

17. 3. Light stroking of the skin, or effleurage, is commonly used with the Lamaze method of
       childbirth preparation. Light abdominal massage with just enough pressure to avoid tickling is thought
       to displace the pain sensation during a contraction. Deep kneading and secure grasping are typically
       associated with relaxation massages to relieve stress. Prolonged pressure on specific sites is
       associated with acupressure.
       CN: Health promotion and maintenance; CL: Apply

Question 18

18. A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to
    aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly
    contraindicated for clients with which of the following?
19. Ruptured membranes.
20. Multifetal gestation.
21. Diabetes mellitus.
22. Hypotonic labor patterns.

Answer 18

18. 1. Some primary health care providers do not allow clients with ruptured membranes to use a
       hot tub or jet hydrotherapy tub during labor for fear of infections. The temperature of the water should
       be between 98°F and 100°F (36.7°C to 37.8°C) to prevent hyperthermia. Jet hydrotherapy is not
       contraindicated for clients with multifetal gestation, diabetes mellitus, or hypotonic labor patterns.
       CN: Reduction of risk potential; CL: Synthesize

Question 19

19. A primigravid client admitted to the labor area in early labor tells the nurse that her brother
    was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can
    tell the client that cystic fibrosis is:
20. X-linked recessive and the disease will only occur if the baby is a boy.
21. X-linked dominant and there is no likelihood of the baby having cystic fibrosis.
22. Autosomal recessive and that unless the baby’s father has the gene, the baby will not have the
    disease.
23. Autosomal dominant and there is a 50% chance of the baby having the disease.

Answer 19

19. 3. Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive
       traits. Such diseases do not occur unless there are two genes for the disease present. If one of the
       parents does not have the gene, the child will not have the disease. X-linked recessive genes can
       result in hemophilia A or color blindness. X-linked recessive genes are present only on the X
       chromosome and are typically manifested in the male child. X-linked dominant genes, which are
       located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an
       inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and
       excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and
       children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan’s syndrome,
       and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait ispresent along with a corresponding healthy recessive gene.
       CN: Health promotion and maintenance; CL: Apply

Question 20

20. The primary health care provider prescribes an amniocentesis for a primigravid client at 35
    weeks’ gestation in early labor to determine fetal lung maturity. Which of the following is an indicator
    of fetal lung maturity?
21. Amount of bilirubin present.
22. Presence of red blood cells.
23. Barr body determination.
24. Lecithin-sphingomyelin (L/S ratio).

Answer 20

20. 4. To determine fetal lung maturity, the sample of amniotic fluid will be tested for the L/S
       ratio. When fetal lungs are mature, the ratio should be 2:1. Bilirubin indicates hemolysis and, if
       present in the fluid, suggests Rh disease. Red blood cells should not appear in the amniotic fluid
       because their presence suggests fetal bleeding. Barr body determination is a chromosome analysis of
       the sex chromosomes that is sometimes used when a child is born with ambiguous genitalia.
       CN: Health promotion and maintenance; CL: Analyze

Question 21

21. Assessment of a 15-year-old primigravid client at term in active labor reveals cervical
    dilation at 7 cm with complete effacement. The nurse should assess the client for which of the
    following first?
22. Uterine inversion.
23. Cephalopelvic disproportion (CPD).
24. Rapid third stage of labor.
25. Decreased ability to push.

Answer 21

21. 2. Adolescent pregnancy carries an increased risk of pregnancy-induced hypertension, iron-
       deficiency anemia, and CPD. CPD is a concern because maturation of the skeletal bones (including
       the pelvis) is commonly not complete in adolescents. Adolescent labor does not differ from labor in
       the older woman if no CPD is present. A prolonged first stage of labor and poor fetal descent may
       indicate that CPD exists. Uterine inversion, a rapid third stage of labor, or decreased ability to push
       may occur regardless of the client’s age.
       CN: Reduction of risk potential; CL: Analyze

Question 22

22. A 19-year-old primigravid client at 38 weeks’ gestation is 7 cm dilated and the presenting
    part is at +1 station, the client tells the nurse, “I need to push!” Which of the following would the
    nurse do next?
23. Use the McDonald procedure to widen the pelvic opening.
24. Increase the rate of oxygen and intravenous fluids.
25. Instruct the client to use a pant-blow pattern of breathing.
26. Tell the client to push only when absolutely necessary.

Answer 22

22. 3. Pushing during the first stage of labor, when the urge is felt but the cervix is not completely
       dilated, may produce cervical swelling, making labor more difficult. The client should be encouraged
       to use a pant-blow (or blow-blow) pattern of breathing to help overcome the urge to push. The
       McDonald procedure is used for cervical cerclage for an incompetent cervix and is inappropriate
       here. Increasing the rate of oxygen and intravenous fluids will not alleviate the pressure that the client
       is feeling. The client should not push even if she feels the urge to do so because this may result in
       cervical edema at 7-cm dilation.
       CN: Health promotion and maintenance; CL: Synthesize

Question 23

23. Which of the following would be the priority when caring for a primigravid client whose
    cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or
    anesthesia?
24. Giving frequent sips of water.
25. Applying extra blankets for warmth.
26. Providing frequent perineal cleansing.
27. Offering encouragement and support.

Answer 23

23. 4. The client is in the transition phase of the first stage of labor. During this phase, the client
       needs encouragement and support because this is a difficult and painful time, when contractions are
       especially strong. Usually, the client finds it difficult to maintain self-control. Everything else seems
       secondary to her as she progresses into the second stage of labor. Although ice chips may be given,
       typically the client does not desire sips of water. Labor is hard work. Generally, the client is
       perspiring and does not desire additional warmth. Frequent perineal cleansing is not necessary unless
       there is excessive amniotic fluid leaking.
       CN: Health promotion and maintenance; CL: Synthesize

Question 24

24. To determine whether a primigravid client in labor with a fetus in the left occipitoanterior
    (LOA) position is completely dilated, the nurse performs a vaginal examination. During the
    examination the nurse should palpate which of the following cranial sutures?
25. Sagittal.
26. Lambdoidal.
27. Coronal.
28. Frontal.

Answer 24

24. 1. The sagittal suture is the most readily felt during a vaginal examination. When the fetus is in
       the LOA position, the occiput faces the mother’s left. The lambdoid suture is on the side of the skull.
       The coronal suture is a horizontal suture across the front portion of the fetal skull that forms the
       anterior fontanel. It may be felt with a brow presentation. The frontal suture may be felt with a brow
       or face presentation.
       CN: Health promotion and maintenance; CL: Apply

Question 25

25. After a lengthy labor process, a primigravid client gives birth to a healthy newborn boy with
    a moderate amount of skull molding. Which of the following would the nurse include when explaining
    to the parents about this condition?
26. It is typically seen with breech births.
27. It usually lasts a day or two before resolving.
28. It is unusual when the brow is the presenting part.
29. Surgical intervention may be necessary to alleviate pressure.

Answer 25

25. 2. Molding occurs with vaginal births and is commonly seen in newborns. This is especially
       true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that
       it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present
       if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.CN: Health promotion and maintenance; CL: Create

Question 26

26. A primiparous client has just given birth. The primary health care provider has informed the
    labor nurse that he believes the uterus has inverted. Which of the following would help to confirm this
    diagnosis? Select all that apply.
27. Hypotension.
28. Gush of blood from the vagina.
29. Intense, severe, tearing type of abdominal pain.
30. Uterus is hard and in a constant state of contraction.
31. Inability to palpate the uterus.
32. Diaphoresis.

Answer 26

26. 1,2,5,6. Uterine inversion is indicated by a sudden gush of blood from the vagina leading to
    decreased blood pressure, and an inability to palpate the uterus since it may be in or protruding from
    the vagina and any signs of blood loss such as diaphoresis, paleness, or dizziness could be observed
    at this time. Intense pain and a hard contracting uterus are not associated with uterine inversion.
    CN: Reduction of risk potential; CL: Analyze

Question 27

27. After the birth of a viable neonate, a 20-year-old primiparous client comments to her mother
    and the nurse about the baby. Which of the following comments would the nurse interpret as a
    possible sign of potential maternal-infant bonding problems?
28. “He’s got my funny-looking ears!”
29. “I think my mother should give him the first feeding.”
30. “He’s a lot bigger than I expected him to be.”
31. “I want to buy him a blue outfit to wear when we get home.”

Answer 27

27. 2. Avoidance, hostility, or low-key (passive) behavior toward the baby may be a cue to
       potential bonding problems. The nurse should encourage the client to give the baby the first feeding to
       begin the bonding process. Expressions of disappointment with the baby’s gender may also signal
       problems with maternal-infant bonding. Comparing the baby’s features to her own indicates
       identification of the neonate as belonging to her, suggesting bonding with neonate. Comparing the
       actual neonate with the “fantasized neonate” is a normal maternal reaction. Wanting to buy a blue
       outfit indicates an interest in and connection with the neonate and is a sign of bonding.
       CN: Reduction of risk potential; CL: Analyze

Question 28

28. The nurse explains to a newly admitted primigravid client in active labor that, according to
    the gate-control theory of pain, a closed gate means that the client should experience which of the
    following?
29. No pain.
30. Sharp pain.
31. Light pain.
32. Moderate pain.

Answer 28

28. 1. According to the gate-control theory of pain, a closed gate means that the client should feel
       no pain. The gate-control theory of pain refers to the gate-control mechanisms in the substantia
       gelatinosa that are capable of halting an impulse at the level of the spinal cord so the impulse is never
       perceived at the brain level as pain (ie, a process similar to keeping a gate closed).
       CN: Health promotion and maintenance; CL: Evaluate

Question 29

29. The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours
    ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to
    push, the nurse should assess:
30. Fetal heart rate variability.
31. Cervical dilation again.
32. Status of membranes.
33. Bladder status.

Answer 29

29. 4. The bladder status should be monitored throughout the labor process, but especially before
       the client begins pushing. A full bladder can impede the progress of labor and slow fetal descent.
       Because she has had an epidural anesthetic, it is most likely that the client is receiving intravenous
       fluids, contributing to a full bladder. The client also does not feel the urge to void because of the
       anesthetic. Although it is important to monitor membrane status and fetal heart rate variability
       throughout labor, this does not affect the client’s ability to push. There is no need to recheck cervical
       dilation because increasing the frequency of examinations can increase the client’s risk for infection.
       CN: Reduction of risk potential; CL: Analyze

Question 30

30. For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes
    has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability.
    After determining that the client is still in the latent phase of labor, the nurse should observe the client
    for:
31. Exhaustion.
32. Chills and fever.
33. Fluid overload.
34. Meconium-stained fluid.

Answer 30

30. 1. The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client
       is having prolonged labor, the nurse should monitor the client for signs of exhaustion as well as
       dehydration. Hypotonic contractions, which are painful but ineffective, may be occurring. Oxytocin
       augmentation may be necessary. Chills and fever are manifestations of an infection and are not
       associated with a prolonged latent phase of labor. Fluid overload can occur from rapid infusion of
       intravenous fluids administered if the client is experiencing hemorrhage or shock. It is not associated
       with prolonged latent phase. The client’s membranes are intact, so it would be difficult to assess
       meconium staining of the fluid. Meconium-stained fluid is associated with fetal distress, and this fetus
       appears to be in a healthy state, as evidenced by a fetal heart rate within normal range and good
       variability.
       CN: Reduction of risk potential; CL: Analyze

Question 31

31. A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left
    occipitoposterior (LOP) position requests pain relief for severe back pain. The nurse should:
32. Provide firm pressure to the client’s sacral area.
33. Prepare the client for a cesarean birth.3. Prepare the client for a precipitate birth.
34. Maintain the client in a left side-lying position.

Answer 31

31. 1. The client who has back pain during labor experiences marked discomfort because the fetus
       is in an LOP position. This pain is much greater than when the fetus is in the anterior position because
       the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application offirm pressure to the sacral area can help alleviate the pain. Problems of severe back pain during labor
       do not typically require a cesarean birth. The primary health care provider may elect to do an
       episiotomy, but it is not necessarily required. It is unlikely that a primigravid client with a fetus in an
       LOP position will have a precipitous birth; rather, labor is usually more prolonged. A hands-and-
       knees position or a right side-lying position may help to rotate the fetal head and thus alleviate some
       of the back pain.
       CN: Health promotion and maintenance; CL: Synthesize

Question 32

32. A primigravid client in active labor has had no anesthesia. The client’s cervix is 7 cm dilated,
    and she is starting to feel considerable discomfort during contractions. The nurse should instruct the
    client to change from slow chest breathing to which of the following?
33. Rapid, shallow chest breathing.
34. Deep chest breathing.
35. Rapid pant-blow breathing.
36. Slow abdominal breathing.

Answer 32

32. 1. The psychoprophylaxis method of childbirth suggests using slow chest breathing until it
       becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at
       the sternum) during the peak of a contraction. The rate is 50 to 70 breaths/min. Deep chest breathing
       is appropriate for the early phase of labor, in which the client exhibits less frequent contractions.
       When transition nears, a rapid pant-blow pattern of breathing is used. Slow abdominal breathing is
       very difficult for clients in labor.
       CN: Health promotion and maintenance; CL: Apply

Question 33

33. The primary health care provider prescribes scalp stimulation of the fetal head for a
    primigravid client in active labor. When explaining to the client about this procedure, which of the
    following would the nurse include as the purpose?
34. Assessment of the fetal hematocrit level.
35. Increase in the strength of the contractions.
36. Increase in the fetal heart rate and variability.
37. Assessment of fetal position.

Answer 33

33. 3. Fetal scalp stimulation is commonly prescribed when there is decreased fetal heart rate
       variability. Pressure is applied with the fingers to the fetal scalp through the dilated cervix. This
       should cause a tactile response in the fetus and increase the fetal heart rate and variability. However,
       if the fetus is in distress and becoming acidotic, fetal heart rate acceleration will not occur. The fetal
       hematocrit level can be measured by fetal blood sampling. Scalp stimulation does not increase the
       strength of the contractions. However, it can increase fetal heart rate and variability. Fetal position is
       assessed by identifying skull landmarks (sutures) during a vaginal examination.
       CN: Reduction of risk potential; CL: Apply

Question 34

34. The nurse is caring for a primigravid client in active labor who has had two fetal blood
    samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis
    when the scalp blood pH is below which of the following?
35. 7.5.
36. 7.4.
37. 7.3.
38. 7.2.

Answer 34

34. 4. If the fetus is hypoxic, the pH will fall below 7.2 and be indicative of fetal distress. This
       finding typically requires immediate vaginal or cesarean birth. A scalp pH reading of 7.21 to 7.25
       should be repeated again in 30 minutes for assessment of hypoxia and acidosis.
       CN: Physiological adaptation; CL: Analyze

Question 35

35. Assessment of a primigravid client reveals cervical dilation at 8 cm and complete
    effacement. The client has severe back pain during this phase of labor. The nurse explains that the
    client’s severe back pain is most likely caused by the fetal occiput being in a position that is identified
    as which of the following?
36. Breech.
37. Transverse.
38. Posterior.
39. Anterior.

Answer 35

35. 3. When a client has severe back pain during labor, the fetus is most likely in an
       occipitoposterior position. This means that the fetal head presses against the client’s sacrum, causing
       marked discomfort during contractions. These sensations may be so intense that the client requests
       medication for relief of the back pain rather than the contractions. Breech presentation and transverse
       lie are usually known prior to 8-cm dilation and a cesarean section is performed. Fetal occiput
       anterior position does not increase the pain felt during labor.
       CN: Health promotion and maintenance; CL: Apply

Question 36

36. The nurse assesses a primiparous client with ruptured membranes in labor for 20 hours. The
    nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client
    with this wave pattern. Which interventions should the nurse perform? Select all that apply.
37. Administering oxygen via mask to the client.
38. Questioning the client about the effectiveness of pain relief.
39. Placing the client on her side.
40. Readjusting the monitor to a more comfortable position.
41. Applying an internal fetal monitor.

Answer 36

36. 1,3,5. Decelerations alert the nurse that the fetus is experiencing decreased blood flow from
    the placenta. Administering oxygen will increase tissue perfusion. Placing the mother on her side will
    increase placental perfusion and decrease cord compression. Using an internal fetal monitor would
    help in identifying the possible underlying cause of the decelerations, such as metabolic acidosis.
    Assessing for pain relief and readjusting the monitor would have no effect on correcting the late
    decelerations.
    CN: Reduction of risk potential; CL: Synthesize

Question 37

37. When performing Leopold’s maneuvers on a primigravid client, the nurse is palpating the
    uterus as shown below. Which of the following maneuvers is the nurse performing?1. First maneuver.
38. Second maneuver.
39. Third maneuver.
40. Fourth maneuver.

Answer 37

37. 3. The third maneuver involves grasping the lower portion of the abdomen just above thesymphysis pubis between the thumb and index finger. This maneuver determines whether the fetal
       presenting part is engaged. The first maneuver involves facing the woman’s head and using the tips of
       the fingers to palpate the uterine fundus. This maneuver is used to identify the part of the fetus that lies
       over the inlet to the pelvis. The second maneuver involves placing the palms of each hand on either
       side of the abdomen to locate the back of the fetus. The fourth maneuver involves placing fingers on
       both sides of the uterus and pressing downward and inward in the direction of the birth canal. This
       maneuver is done to determine fetal attitude and degree of extension and should only be done if the
       fetus is in the cephalic presentation.
       CN: Physiological adaptation; CL: Apply

Question 38

38. Before placing the fetal monitoring device on a primigravid client’s fundus, the nurse
    performs Leopold’s maneuvers. When performing the third maneuver, the nurse explains that this
    maneuver is done for which of the following reasons?
39. To determine whether the fetal presenting part is engaged.
40. To locate the fetal cephalic prominence.
41. To distinguish between a breech and a cephalic presentation.
42. To locate the position of the fetal arms and legs.

Answer 38

38. 1. Leopold’s maneuvers are performed to determine the presentation and position of the fetus.
       The third maneuver determines whether the fetal presenting part is engaged in the maternal pelvis.
       The first maneuver distinguishes between a breech and a cephalic presentation through palpation of
       the top of the fundus. The second maneuver locates the fetal back, arms, and legs. The fetal heart rate
       monitoring device should be placed near the fetal skull and back for optimal fetal heart rate
       monitoring. The fourth maneuver is done to locate the fetal cephalic prominence if the fetus is in a
       cephalic position.
       CN: Health promotion and maintenance; CL: Apply

Question 39

39. One-half hour after vaginal birth of a term neonate, the nurse palpates the fundus of a
    primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The
    client’s blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?
40. Continue to monitor the client’s fundus every 15 minutes.
41. Ask the primary health care provider for a prescription for methylergonovine.
42. Immediately notify the primary health care provider of the client’s symptoms.
43. Change the client’s perineal pads every 15 minutes.

Answer 39

39. 3. Small clots that are expressed during fundal examination in the immediate postpartum
       period are normal; however, large clots are indicative of retained placental tissue. A small trickle of
       bright red vaginal bleeding may indicate a laceration. The nurse should notify the primary health care
       provider immediately of these findings, because uterine atony may occur and the laceration, if
       present, needs to be repaired to prevent further blood loss. Continuing to monitor the client every 15
       minutes is the standard of care for a postpartum client. Taking no action would indicate that the nurse
       thinks passage of clots and trickling of bright red blood is a normal situation, which it is not.
       Methylergonovine is a powerful drug that contracts the uterus, but it usually is not administered to a
       client with a blood pressure of 136/92 mm Hg because of its hypertensive effects. Changing the
       perineal pads every 15 minutes is not helpful if the client is experiencing a hemorrhage.
       CN: Health promotion and maintenance; CL: Synthesize

Question 40

The Multigravid Client in Labor
40. The nurse is caring for a G2 P1 client at term. The client is completely effaced, dilated to 2
cm with contractions every 3 minutes lasting 45 seconds. The client is asking for an epidural to make
her more comfortable. Indicate the appropriate response by the nurse.
1. You are unable to have the epidural until you are 5 to 6 cm dilated as the labor may be slowed
if given earlier. There is IV medication available if you would like it now.
2. When your membranes have ruptured, you will be ready to have the epidural. This is the usual
time to start the epidural.
3. Your contraction pattern is slow at this point and will need to accelerate before you can have
your epidural.
4. It is too early in labor for the epidural but your obstetrician has prescribed IV medication to
keep you comfortable until you have dilated 1 to 2 cm more

Answer 40

The Multigravid Client in Labor
40. 4. Epidurals are given when labor is established, usually at 3- to 4-cm dilation. The effect of
the epidural should be that labor will continue and not be slowed down by the administration of the
epidural. The use of an epidural is not correlated with rupture of membranes. The contraction pattern
for this client is adequate, not slow, and considered normal for 2 cm dilation. Epidurals are given at
3- to 4-cm dilation, and if there is medication available, it can be given to make the client
comfortable until an epidural can be given.
CN: Management of care; CL: Apply

Question 41

41. The nurse has just received report on a labor client: a G3 T1 P0 Ab1 L1who is 80/3/0, (80%
    effaced, 3 cm dilated, 0 station). The nurse anticipates the plan of care for the next shift will include
    which of the following? Select all that apply.
42. A birth before the change of shift in 12 hours.
43. Pushing the baby out should take 30 minutes or less.
44. Contractions will remain irregular until transition.
45. Transition will be shorter for this multiparous client.
46. This client will withdraw into herself during transition.

Answer 41

41. 1,2,4,5. A multiparous client usually gives birth within 12 hours of the time labor began. The
    pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from
    10-cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration
    as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a
    multiparous client than it will for a primiparous client, as the entire labor process takes less time forsomeone who has had a baby before. This client will withdraw into herself during transition and this
    is a common characteristic for those in the transition phase.
    CN: Management of care; CL: Create

Question 42

42. A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with
    moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What
    should the nurse do next?
43. Perform a vaginal examination.
44. Notify the primary health care provider of the decelerations.
45. Reposition the client and continue to evaluate the tracing.
46. Administer oxygen via mask at 2 L/min.

Answer 42

42. 3. The cause of variable decelerations is cord compression, which may be relieved by
       moving the client to one side or another. If the client is already on the left side, changing the client to
       the right side is appropriate. Performing a vaginal examination will let the nurse know how far
       dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by
       position changes, oxygen should be initiated but the rate should be 8 to 10 L/min. Notifying the
       primary health care provider should occur if turning the client and administering oxygen do not
       relieve the decelerations.
       CN: Management of care; CL: Synthesize

Question 43

43. A nurse is preparing a change-of-shift report and has been caring for a multigravid client with
    a normally progressing labor. Which of the following information should be part of this report? Select
    all that apply.
44. Interpretation of the fetal monitor strip.
45. Analgesia or anesthesia being used.
46. Anticipated method of birth control.
47. Amount of vaginal bleeding or discharge.
48. Support persons with the client.
49. Prior birth history.

Answer 43

43. 1,2,4,5,6. Knowledge of how the fetus is tolerating contractions as well as the frequency,
    intensity, and duration of contractions, as indicated on the fetal monitor strip, are extremely important.
    The type of analgesia or anesthesia being used, the client’s response, and her pain rating should be
    included as well. The amount of vaginal bleeding indicates whether this labor is in the normal range.
    Vaginal discharge indicates if membranes are ruptured and the color, odor, and amount of amniotic
    fluid. The support persons with the client are an integral part of the labor process and greatly
    influence how she manages labor emotionally and, commonly, physically. A complete change-of-shift
    report would include the client’s name, age, gravida and parity, current and prior illnesses that may
    influence this hospitalization, prior labor and birth history if applicable, last vaginal examination time
    and findings, vaginal bleeding, support persons with client, current IVs and other medications being
    used, and pertinent laboratory test results. Future plan for birth control would be the least important
    information to be given to the next shift because it will not impact the labor care plan.
    CN: Physiological adaptation; CL: Create

Question 44

44. A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse
    gives the client nalbuphine 15 mg. Within 5 minutes, the client tells the nurse she feels like she needs
    to have a bowel movement. The nurse should first:
45. Have naloxone hydrochloride (Narcan) available in the birthing room.
46. Complete a vaginal examination to determine dilation, effacement, and station.3. Prepare for birth.
47. Document the client’s relief due to pain medication.

Answer 44

44. 2. The feeling of needing to have a bowel movement is commonly caused by pressure on the
       receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually
       indicates advances in fetal station and that the client may be close to birth. The nurse should respond
       initially to the client’s signs and symptoms by checking to validate current effacement, dilation, and
       station. If the fetus is ready to be born, having the room ready for the birth and having naloxone
       hydrochloride (Narcan) available are important. Narcan completely or partially reverses the effects
       of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time
       away from the vaginal examination, preparing for birth, and obtaining Narcan. The birth may be
       occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.
       CN: Safety and infection control; CL: Synthesize

Question 45

45. A multigravid laboring client has an extensive documented history of drug addiction. Her last
    reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate
    intensity. The primary health care provider prescribes nalbuphine 15 mg slow IV push for pain relief
    followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the
    nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs
    available at the time of the birth, which should the nurse avoid using with this client in this situation?
46. 1% lidocaine (Xylocaine).
47. Naloxone hydrochloride (Narcan).
48. Local anesthetic.
49. Pudendal block.

Answer 45

45. 2. Naloxone hydrochloride (Narcan) would not be used in a client who has a history of drug
       addiction. Narcan would abruptly withdraw this woman from the drug she is addicted to as well as
       the nalbuphine. The withdrawal would occur within a few minutes of injection and, if severe enough,
       could jeopardize the mother and fetus. Xylocaine is a local anesthetic and numbs rather than
       decreases the effects of Narcan. The local anesthetic and the pudendal block are both appropriate for
       this birth but are used to numb the maternal perineum for birth.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 46

46. A 31-year-old multigravid client at 39 weeks’ gestation admitted to the hospital in active
    labor is receiving intravenous lactated Ringer’s solution and a continuous epidural anesthetic. During
    the first hour after administration of the anesthetic, the nurse should monitor the client for:
47. Hypotension.
48. Diaphoresis.
49. Headache.
50. Tremors.

Answer 46

46. 1. When a client receives an epidural anesthetic, sympathetic nerves are blocked along withthe pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include
       bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed
       respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not
       usually associated with the administration of epidural anesthesia. Headache, a common adverse effect
       of many drugs, also is not associated with administration of epidural anesthesia.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 47

47. A 30-year-old G 3, P 2 is being monitored internally. She is being induced with IV oxytocin
    because she is postterm. The nurse notes the pattern below. The client is wedged to her side while
    lying in bed and is approximately 6 cm dilated and 100% effaced. The nurse should first:
48. Continue to observe the fetal monitor.
49. Anticipate rupture of the membranes.
50. Prepare for fetal oximetry.
51. Discontinue the oxytocin infusion.

Answer 47

47. 4. The fetal monitor strip shows late decelerations. The first intervention would be to turn off
       the oxytocin because the medication is causing the contractions. The stress caused by the contractions
       demonstrates that the fetus is not being perfused during the entire contraction (as shown by the late
       decelerations). There is no time to continue to observe in this situation; intervention is a priority. The
       client is attached to an internal fetal monitor, which would be possible only if her membranes had
       already ruptured. If the fetus continues to experience stress, fetal oximetry may be initiated.
       CN: Physiological adaptation; CL: Analyze

Question 48

48. The nurse, while shopping in a local department store, hears a multiparous woman say
    loudly, “I think the baby’s coming.” After asking someone to call 911, the nurse assists the client to
    give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother
    initiate breast-feeding, primarily for which of the following reasons?
49. To begin the parental-infant bonding process.2. To prevent neonatal hypothermia.
50. To provide glucose to the neonate.
51. To contract the mother’s uterus.

Answer 48

48. 4. After an emergency birth, the nurse suggests that the mother begin breast-feeding to contract
       the uterus. Breast-feeding stimulates the natural production of oxytocin. In a multiparous client,
       uterine atony is a potential complication because of the stretching of the uterine fibers following each
       subsequent pregnancy. Although breast-feeding does help to begin the parental-infant bonding
       process, this is not the primary reason for the nurse to suggest breast-feeding. Prevention of neonatal
       hypothermia is accomplished by placing blankets on both the neonate and the mother. Although
       colostrum in breast milk provides the neonate with nutrients and immunoglobulins, the primary reason
       for breast-feeding is to stimulate the natural production of oxytocin to contract the uterus.
       CN: Reduction of risk potential; CL: Apply

Question 49

49. Approximately 15 minutes after birth of a viable term neonate, a multiparous client has chills.
    Which of the following should the nurse do next?
50. Assess the client’s pulse rate.
51. Decrease the rate of intravenous fluids.
52. Provide the client with a warm blanket.
53. Assess the amount of blood loss.

Answer 49

49. 3. A chill shortly after birth is a common, normal occurrence. Warm blankets can help provide
       comfort for the client. It has been suggested that the shivering response is caused by a difference
       between internal and external body temperatures. A different theory proposes that the woman is
       reacting to fetal cells that have entered the maternal bloodstream through the placental site. Assessing
       the client’s pulse rate will provide no further information about the chill. Decreasing the IV rate will
       not influence the length of time the client trembles. Assessing blood loss is a standard of care at this
       point postpartum but has no correlation to the chill.
       CN: Health promotion and maintenance; CL: Synthesize

Question 50

50. The primary health care provider plans to perform an amniotomy on a multiparous client
    admitted to the labor area at 41 weeks’ gestation for labor induction. After the amniotomy, the nurse
    should first:
51. Monitor the client’s contraction pattern.
52. Assess the fetal heart rate (FHR) for 1 full minute.
53. Assess the client’s temperature and pulse.
54. Document the color of the amniotic fluid.

Answer 50

50. 2. After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of
       the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm
       or less should be promptly reported to the primary health care provider. A cord prolapse requires
       prompt birth by cesarean section. The client’s contraction pattern should be monitored once labor has
       been established. The client’s temperature, pulse, and respirations should be assessed every 2 to 4
       hours after rupture of the membranes to detect an infection. The nurse should document the color,
       quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal
       pattern is present.
       CN: Health promotion and maintenance; CL: Synthesize

Question 51

51. A multigravid client who is 10 cm dilated is admitted to the labor and birth unit. In addition
    to supporting the client, priority nursing care includes:
52. Turning on the infant warmer.
53. Increasing IV fluids.
54. Determining the client’s preferences for pain control.
55. Providing client education regarding care of the newborn.

Answer 51

51. 1. Nursing care for this client includes providing support, preparing for childbirth, assessing
       for potential complications, and providing for care of the newborn. Turning on the warmer is the best
       choice for providing for the care of the newborn. Oxygen and IV fluids may be indicated if variableor late decelerations are noted on the fetal heart monitor, but decelerations are not indicated in the
       question. It is likely too late for pharmacologic pain relief for a multigravid client. Education
       regarding care of the newborn is not appropriate at this time.
       CN: Management of care; CL: Apply

Question 52

52. Which of the following would the nurse expect as a common finding for a multiparous client
    giving birth to a viable neonate at 41 weeks’ gestation with the aid of a vacuum extractor?
53. Caput succedaneum.
54. Cephalohematoma.
55. Maternal lacerations.
56. Neonatal intracranial hemorrhage.

Answer 52

52. 1. Caput succedaneum is common after the use of a vacuum extractor to assist the client’s
       expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with
       cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used.
       Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is
       not a common finding.
       CN: Health promotion and maintenance; CL: Analyze

Question 53

53. The nurse is assessing fetal presentation in a multiparous client. The illustration below
    indicates which of the following types of presentation?1. Frank breech.
54. Complete breech.
55. Footling breech.
56. Vertex.

Answer 53

53. 1. Breech presentations account for 5% of all births and the most common is frank breech. In
       frank breech, there is flexion of the fetal thighs and extension of the knees. The feet rest at the side of
       the fetal head. In complete breech, there is flexion of the fetal thighs and knees; the fetus appears to be
       squatting. Footling breech occurs when there is an extension of the fetal knees and one or both feet
       protrude through the cervix. Vertex presentation occurs in 95% of births with the head engaged in the
       pelvis.
       CN: Physiological adaptation; CL: Apply

Question 54

54. Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5
    cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and
    vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should
    first:
55. Warm the temperature of the room by a few degrees.
56. Increase the rate of intravenous fluid administration.
57. Obtain a prescription for an intramuscular antiemetic medication.
58. Assess the client’s cervical dilation and station.

Answer 54

54. 4. The nurse should assess the client’s cervical dilation and station, because the client’s
       symptoms are indicative of the transition phase of labor. Multiparous clients can proceed 5 to 9 cm/h
       during the active phase of labor. Warming the temperature of the room is not helpful because the client
       will soon be ready to begin expulsive pushing. Increasing the intravenous fluid rate is not warranted
       unless the client is experiencing dehydration. Administration of an antiemetic at this point in labor is
       not warranted and may result in neonatal depression should a rapid birth occur.
       CN: Health promotion and maintenance; CL: Synthesize

Question 55

55. When assessing the frequency of contractions of a multiparous client in active labor admitted
    to the birthing area, the nurse should assess the interval between which of the following?
56. Acme of one contraction to the beginning of the next contraction.
57. Beginning of one contraction to the end of the next contraction.
58. End of one contraction to the end of the next contraction.
59. Beginning of one contraction to the beginning of the next contraction.

Answer 55

55. 4. To assess the frequency of the client’s contractions, the nurse should assess the interval
       from the beginning of one contraction to the beginning of the next contraction. The duration of a
       contraction is the interval between the beginning and the end of a contraction. The acme identifies the
       peak of a contraction.
       CN: Health promotion and maintenance; CL: Analyze

Question 56

56. While a client is being admitted to the birthing unit she states, “My water broke last night, but
    my labor started two hours ago.” Which of the following is a concern? Select all that apply.
57. Maternal vital signs: T 99.5 (37.5), HR 80, R 24, BP 130/80 mm Hg.
58. Blood and mucus on perineal pad.
59. Baseline fetal heart rate of 140 with a range between 110 and 160 with contractions.
60. Peripad stained with green fluid.
61. The client states, “This baby wants out—he keeps kicking me.”

Answer 56

56. 3,4,5. The range of fetal heart rate fluctuating too high and low could indicate fetal distress.
    The green peripad fluid indicates meconium, which could be associated with fetal distress. Increased
    fetal activity during labor may also indicate distress. The maternal vital signs noted and a perineal
    pad with blood and mucus are normal findings.
    CN: Reduction of risk potential; CL: Analyze

Question 57

57. While the nurse is caring for a multiparous client in active labor at 36 weeks’ gestation, theclient tells the nurse, “I think my water just broke.” Which of the following should the nurse do first?
58. Turn the client to the right side.
59. Assess the color, amount, and odor of the fluid.
60. Assess the fetal heart rate pattern.
61. Check the client’s cervical dilation.

Answer 57

57. 3. After spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical
       cord out of the birth canal. Sudden deceleration of the fetal heart rate commonly signifies cord
       compression and/or prolapse of the cord, which would require immediate birth. This client is
       particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the
       client to the right side is not a priority action. However, changing the client’s position would be
       appropriate if variable decelerations are present. The nurse should assess the color, amount, and odor
       of the fluid, but this can be done once the fetal heart rate is assessed and no problems are detected.Cervical dilation should be checked but only after the fetal heart rate pattern is assessed.
       CN: Reduction of risk potential; CL: Synthesize

Question 58

58. The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The
    woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which
    actions would be appropriate? Select all that apply.
59. Assisting her to the bathroom.
60. Applying an external fetal monitor to obtain fetal heart rate.
61. Assessing her stage of labor.
62. Asking if she had back labor pains like this with any of her other childbirth experiences.
63. Allowing her support person to take her to the bathroom to maintain privacy.
64. Checking the degree of fetal descent.

Answer 58

58. 3,6. The pressure from the fetus descending into the birth canal can cause the client to feel she
    needs to move her bowels and could be near childbirth. Failure to assess the stage of labor and
    degree of fetal descent before allowing the client to go to the bathroom may lead to progression of
    labor and could result in a birth in the bathroom. Applying a fetal monitor may reassure the nurse that
    the fetus is doing well; however, it does not help to determine if the fetus is ready to be born, which is
    the higher priority in this situation. Regardless of the client’s prior experience with back labor pain,
    the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the
    feeling of pressure with a bowel movement.
    CN: Safety and infection control; CL: Synthesize

Question 59

59. A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal
    anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has
    understood the instructions when she says which of the following?
60. “The medication will be administered while I am in prone position.”
61. “The anesthetic may cause a severe headache which is treatable.”
62. “My blood pressure may increase if I lie down too soon after the injection.”
63. “I can expect immediate anesthesia that can be reversed very easily.”

Answer 59

59. 2. Spinal anesthesia is used less commonly today because of preference for epidural block
       anesthesia. One of the adverse effects of spinal anesthesia is a “spinal headache” caused by leakage
       of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead,
       keeping the client in a flat position, or using a blood patch that can clot and seal off any further
       leakage of fluid. Spinal anesthesia is administered with the client in a sitting position or side lying.
       Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia
       provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to
       30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers
       oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 60

60. When developing the plan of care for a multiparous client in active labor who receives an
    epidural anesthetic, which of the following would the nurse anticipate that the primary health care
    provider will prescribe if the client develops moderate hypotension?
61. Ephedrine.
62. Epinephrine.
63. Methylergonovine
64. Atropine sulfate.

Answer 60

60. 1. The drug of choice when hypotension occurs as a result of epidural anesthesia is ephedrine
       sulfate because it provides a quick reversal of the vasodilator effects of the anesthesia. Epinephrine
       is typically used to treat anaphylactic shock. Methylergonovine is a vasoconstrictor that is used for
       severe postpartum hemorrhage. Atropine sulfate is used to dry the oral and respiratory secretions and
       may be used during operative procedures.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 61

61. The primary health care provider determines that the fetus of a multiparous client in active
    labor is in distress, necessitating a cesarean birth with general anesthesia. Before the cesarean birth,
    the anesthesiologist prescribes cimetidine (Tagamet) 300 mg PO. After administering the drug, the
    nurse should assess the client for reduction in which of the following?
62. Incidence of bronchospasm.
63. Oral and respiratory secretions.
64. Acid level of the stomach contents.
65. Incidence of postoperative gastric ulcer.

Answer 61

61. 3. Cimetidine (Tagamet) is prescribed by some anesthesiologists who will be giving a general
       anesthetic to reduce the level of acid in the stomach contents, altering the pH to reduce the risk of
       complications should aspiration of vomitus occur. Aspiration of vomitus is the fifth most common
       cause of maternal mortality. Most anesthesiologists insert an endotracheal tube to reduce the
       incidence of aspiration. Isoproterenol (Isuprel) is used to decrease the incidence of bronchospasm.
       Atropine sulfate is administered to dry oral and nasal secretions. Although cimetidine is useful for
       gastric ulcer therapy, gastric ulcers are not a common effect associated with operative births.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 62

62. The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration,
    the nurse instructs the client to assume which of the following positions?
63. Lithotomy.
64. Side-lying.
65. Knee-to-chest.
66. Prone.

Answer 62

62. 2. Lumbar epidural anesthesia is usually administered with the client in a sitting or a left side-
       lying position with shoulders parallel and legs slightly flexed. These positions expose the vertebrae
       to the anesthesiologist. Paracervical and local anesthetics are usually administered with the client in
       the lithotomy position. The knee-to-chest and prone positions are not used for anesthesia
       administration.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 63

63. The nurse is assessing the perineal changes of a multigravid client in the second stage of
    labor. The illustration below represents which of the following perineal changes?
64. Anterior-posterior slit.
65. Oval opening.
66. Circular shape.
67. Crowning.

Answer 63

63. 2. Anterior-posterior slit occurs as the perineum flattens and is followed by an oval opening.
       As labor progresses, the perineum takes on a circular shape. Crowning occurs when the fetal head is
       visible.
       CN: Physiological adaptation; CL: Apply

Question 64

64. The nurse is caring for a full-term primiparous client who is in the transition stage of labor.
    The client is writhing in pain and asking “help me, help me!” The epidural redose was 3⁄4 hour ago,
    and she was catheterized just prior to the epidural redose. Her last vaginal exam 1 hour ago showed
    that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does
    the nurse anticipate as the highest priority intervention in caring for this client?
65. Help the client through contractions until the redose is effective.
66. Palpate the bladder to see if it has become distended.
67. Ask the client for suggestions to make her more comfortable.
68. Perform a vaginal exam to determine if the client is fully dilated.

Answer 64

64. 4. Transition is the most difficult period of the labor process and often when clients are tired,
       pain becomes more intensified. Patients during this stage verbalize anger and are outspoken and
       difficult to comfort. The most logical next step would be to determine if the client has completed
       transition and is ready to begin pushing. Performing a vaginal exam would provide this answer. The
       redose of the epidural has had time to be effective. Palpating the bladder is an important intervention
       but not the highest priority as it was done less than an hour ago. Since the nurse has correctly
       completed the most logical steps, asking for the client’s input would certainly be in order but not the
       highest priority intervention.
       CN: Basic care and comfort; CL: Apply

Question 65

The Labor Experience
65. A client is admitted at 30 weeks’ gestation with contractions every 3 minutes. Her cervix is 1
to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2
g/h. How will the nurse know the medication is having the intended effect?
1. Contractions will increase in frequency, leading to birth.
2. The client will maintain a respiratory rate greater than 12 breaths/min.
3. Contractions will decrease in frequency, intensity, and duration.
4. The client will maintain blood pressure readings of 120/80 mm Hg.

Answer 65

The Labor Experience
65. 3. The expected outcome of magnesium sulfate administration is suppression of the
contractions because the client is in preterm labor. Magnesium sulfate is a smooth muscle relaxant
used to slow and stop contractions. Having contractions that lead to birth is not the intended effect of
this drug when used for preterm labor. Respirations lower than 12 breaths/min may indicate
magnesium sulfate toxicity. Another use of magnesium sulfate is to treat preeclampsia by preventing
seizures and, secondarily, lowering maternal blood pressure. However, in this scenario, preterm
labor—not preeclampsia—is being treated.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 66

66. A client at 33 weeks’ gestation is admitted in preterm labor. She is given betamethasone 12
    mg IM every 24 hours × 2. What is the expected outcome of this drug therapy?
67. The contractions will end within 24 hours.
68. The client will give birth to a neonate without infection.
69. The client will give birth to a full-term neonate.
70. The neonate will be born with mature lungs.

Answer 66

66. 4. Betamethasone is a corticosteroid that induces the production of surfactant. The pulmonary
       maturation that results causes the fetal lungs to mature more rapidly than normal. Because the lungs
       are mature, the risk of respiratory distress in the neonate is lowered but not eliminated.
       Betamethasone also decreases the surface tension within the alveoli. Betamethasone has no influence
       on contractions or carrying the fetus to full term. It also does not prevent infection.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 67

67. A full-term client is admitted for an induction of labor. The health care provider has assigned
    a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
68. Oxytocin 30 units in 500 mL D 5 W.
69. Prostaglandin gel 0.5 mg.
70. Misoprostol 50 mcg PO.
71. Dinoprostone 10 mg.

Answer 67

67. 1. A Bishop score evaluates cervical readiness for labor based on five factors: cervical
       softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a
       multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from
       the induction process. The nurse should expect that labor will be induced using oxytocin because the
       Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior
       position. The cervix is soft and the presenting part is at a –1 to 0 position. Prostaglandin gel,
       misoprostol, and dinoprostone are all cervical ripening agents and the doses are accurate; however,
       cervical ripening has already taken place.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 68

68. A full-term client is admitted for induction of labor. When admitted, her cervix is 25/0. The
    initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for
    induction?
69. Nalbuphine.
70. Oxytocin.
71. Dinoprostone.
72. Betamethasone.

Answer 68

68. 3. Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must
       occur before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include
       dinoprostone, misoprostol, and prostaglandin E2. Nalbuphine is a narcotic analgesic used in early
       labor and has no influence on the cervix. Betamethasone is a corticosteroid given to mature fetallungs.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 69

69. The nurse is explaining the medication options available for pain relief during labor. The
    nurse realizes the client needs further teaching when the client states which of the following?
70. “Nalbuphine and promethazine will give relief from pain and nausea during early labor.”
71. “I can have an epidural as soon as I start contracting.”
72. “If I have a cesarean, I can have an epidural.”
73. “If I have an emergency cesarean, I may be put to sleep for the birth.”

Answer 69

69. 2. Typically, a client will be able to have an epidural when she is 3 to 4 cm dilated or the
       active phase of labor has been established. Waiting until the cervix is dilated to this point ensures that
       the client is in labor and the epidural is less likely to halt labor contractions. Nalbuphine and
       promethazine are used to provide relief until the client is about 7 cm dilated. If given after this time,
       narcotics may cause neonatal respiratory depression in the neonate. The majority of clients have an
       epidural or spinal for a cesarean section. The only time general anesthesia is used is for an
       emergency cesarean section.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 70

70. The health care provider has performed an amniotomy on a laboring client. Which of the
    following details must be included in the documentation of this procedure? Select all that apply.
71. Time of rupture.
72. Color and clarity of fluid.
73. Fetal heart rate (FHR) and pattern before and after the procedure.
74. Size of amnio-hook used during the procedure.
75. Odor and amount of fluid.

Answer 70

70. 1,2,3,5. The time of rupture; color, odor, amount, and clarity of amniotic fluid; and FHR and
    pattern before and after the procedure are all information that must be documented on the client’s
    record. There is only one size for an amnio-hook.
    CN: Management of care; CL: Create

Question 71

71. Following an epidural and placement of internal monitors, a client’s labor is augmented.
    Contractions are lasting greater than 90 seconds and occurring every 11⁄2 minutes. The uterine resting
    tone is greater than 20 mm mercury with an abnormal fetal heart rate and pattern. Which of the
    following actions should the nurse take first?
72. Notify the health care provider.
73. Turn off the oxytocin infusion.
74. Turn the client to her left side.
75. Increase the maintenance IV fluids.

Answer 71

71. 2. The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention
       should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions,
       elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin, should the
       nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase
       the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all
       other interventions are initiated, she should notify the health care provider.
       CN: Management of care; CL: Synthesize

Question 72

72. A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial
    actions by the nurse include:
73. Prepare for birth, reposition patient, and begin pushing.
74. Perform sterile vaginal exam, increase IV fluids, and apply oxygen.
75. Notify the provider, explain findings to the patient, and begin pushing.
76. Reposition patient, apply oxygen, and increase IV fluids.

Answer 72

72. 4. Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency.
       Interventions to improve perfusion include repositioning the patient, oxygen, and IV fluids. A sterile
       vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not
       indicate an imminent birth.
       CN: Management of Care; CL: Analyze

Question 73

73. A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15
    seconds and exceeding the baseline with fetal movement. What action associated with this finding
    should the nurse take?
74. Turn the client to her left side.
75. Administer oxygen via facemask at 10 to 12 L/min.
76. Notify the health care provider of the situation.
77. Document fetal well-being.

Answer 73

73. 4. Accelerations that are episodic and occur during fetal movement demonstrate fetal well-
       being. Turning the client to the left side, applying oxygen by face mask and notifying the health care
       provider are interventions used for late and variable decelerations indicating the fetus is not
       tolerating the induction process well.
       CN: Physiological adaptation; CL: Synthesize

Question 74

74. As a nurse begins her shift on the obstetrical unit, there are several new admissions. The
    client with which of the following conditions would be a candidate for induction?
75. Preeclampsia.
76. Active herpes.
77. Face presentation.
78. Fetus with late decelerations.

Answer 74

74. 1. The client with preeclampsia would be a candidate for the induction process because
       ending the pregnancy is the only way to cure preeclampsia. A client with active herpes would be a
       candidate for a cesarean section to prevent the fetus from contracting the virus while passing through
       the birth canal. The woman with a face presentation will not be able to give birth vaginally due to the
       extended position of the neck. The client whose fetus exhibits late decelerations without oxytocin
       would be at greater risk for fetal distress with use of this drug. Late decelerations indicate the fetus
       does not have enough placental reserves to remain oxygenated during the entire contraction. This
       client may require a cesarean section.
       CN: Management of care; CL: Evaluate

Question 75

75. A nurse and an LPN are working in the labor and birth unit. Of the following assessments and
    interventions that must be done immediately, which should the nurse assign to the LPN?
76. Complete an initial assessment on a client.
77. Increase the oxytocin rate on a laboring client.
78. Perform a straight catheterization for protein analysis.
79. Recover a mother following a cesarean birth.

Answer 75

75. 3. The straight catheterization is within the scope of practice of a licensed practical nurse. An
       initial or continuing assessment is the responsibility of the registered nurse. Assessment must be
       complete before increasing the IV rate of oxytocin. The assessment and the increase in oxytocin rate
       are responsibilities for the nurse. The RN, not the LPN, recovers clients who have had surgery
       because frequent assessments are needed.
       CN: Management of care; CL: Evaluate

Question 76

76. A nurse and a nursing assistant are caring for clients in a labor and birth unit. Which task
    should the registered nurse assign to the nursing assistant?
77. Perform a fundal check on a 2-day postpartum client.
78. Remove a fetal monitor and assist a client to the bathroom.
79. Give ibuprofen 800 mg by mouth to a newly postpartum client.
80. Teach a new mother how to bottle-feed her infant.

Answer 76

76. 2. Removing a fetal monitor from a client and assisting her to the bathroom are within the
       realm of practice of a nursing assistant. Performing a fundal check is an assessment, which is a
       responsibility of a registered nurse. A nursing assistant is not permitted to administer medication by
       any route. Education is also part of the professional nursing role. Although a nursing assistant can
       assist a mother with bottle-feeding, the formal client education must be completed and validated by
       the nurse.
       CN: Management of care; CL: Evaluate

Question 77

77. A laboring client smiles pleasantly at the nurse when asked simple questions. The client
    speaks only Mandarin and the interpreter is busy with an emergency situation. At her last vaginal
    examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with thisclient, which of the following responses indicates that the client may be approaching birth?
78. The fetal monitor strip shows late decelerations.
79. The client begins to speak to her family in her native language.
80. The fetal monitor strip shows early decelerations.
81. The client’s facial expressions become animated.

Answer 77

77. 3. When the fetal head is compressed, early decelerations are seen as a vagal response occurs
       and the fetal heart rate decelerates and inversely mirrors the contraction. This response commonly
       occurs when the client is 9 to 10 cm dilated or pushing. If communication cannot be facilitated, early
       decelerations are one indicator that birth may be approaching. Late decelerations may occur at this
       time but indicate uteroplacental insufficiency rather than imminent birth. At any time during the labor
       process, the client may communicate with her family in her native language. The client’s facial
       expressions may change at any point during labor and cannot be used as an indicator of imminent
       birth.
       CN: Physiological adaptation; CL: Analyze

Question 78

The Intrapartal Client with Risk Factors
78. A client is admitted with a suspected abruptio placentae. The nurse should assess the client
for which of the following signs and symptoms? Select all that apply.
1. Bleeding that is concealed or apparent.
2. Abdominal rigidity.
3. Painful abdomen.
4. Painless bleeding.
5. Large placenta.
6. Bleeding that stops spontaneously.

Answer 78

The Intrapartal Client with Risk Factors
78. 1,2,3. With abruptio placentae, bleeding may occur vaginally, may be obstructed by the fetal
head, or it may be hidden behind a portion of the placenta. Abdominal rigidity occurs, particularly
with a concealed hemorrhage because the girth and fundal height increase. Abdominal pain is one of
the classic symptoms of abruption. The pain may be intermittent, as in labor contractions, or
continuous. The placenta with abruption is not larger than a normal placenta and the bleeding does not
end spontaneously.
CN: Physiological adaptation; CL: Analyze

Question 79

79. A multigravid client is in active labor with twins at 38 weeks’ gestation. The nurse should
    monitor the client closely for symptoms of which of the following?
80. Preeclampsia.
81. Urinary tract infection.
82. Chorioamnionitis.
83. Precipitous birth.

Answer 79

79. 1. Clients who are pregnant with two (or more) fetuses are at greater risk for preeclampsia,
       hydramnios, placenta previa, preterm labor, and anemia. During childbirth, occasionally the placenta
       of the second twin separates before that twin is born, causing profound bleeding. Urinary tract
       infections and chorioamnionitis are not more common in clients with multifetal gestation compared
       with women with single-fetus pregnancies. Although multiparous women frequently give birth more
       quickly than a nullipara does, precipitous birth is not more common with twin gestations.
       CN: Reduction of risk potential; CL: Analyze

Question 80

80. A 39-year-old multigravid client at 39 weeks’ gestation admitted to the hospital in active
    labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate
    oxygenation during labor, the nurse plans to encourage the client to do which of the following?
81. Breathe slowly after each contraction.
82. Avoid the use of analgesics for the labor pain.
83. Remain in a side-lying position with the head elevated.
84. Request local anesthesia for vaginal birth.

Answer 80

80. 3. The multigravid client with class II heart disease has a slight limitation of physical activity
       and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler’s position with
       the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by
       mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted.Although breathing slowly during a contraction may assist with oxygenation, it would have no effect
       on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of
       discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may
       reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second
       stage of labor.
       CN: Reduction of risk potential; CL: Synthesize

Question 81

81. When developing the plan of care for a multigravid client with class III heart disease, which
    of the following areas should the nurse expect to assess frequently?
82. Dehydration.
83. Nausea and vomiting.
84. Iron-deficiency anemia.
85. Tachycardia.

Answer 81

81. 4. Assessing for signs and symptoms associated with cardiac decompensation is the priority.
       Class III heart disease during pregnancy has a 25% to 50% mortality. These clients are markedly
       compromised, with marked limitation of physical activity. They frequently experience fatigue,
       palpitations, dyspnea, or anginal pain. A pulse rate greater than 100 bpm or a respiratory rate greater
       than 25 breaths/min may indicate cardiac decompensation that could result in cardiac arrest.
       Additional symptoms include dyspnea, peripheral edema, orthopnea, tachypnea, rales, and
       hemoptysis.
       CN: Reduction of risk potential; CL: Analyze

Question 82

82. A multigravid client in active labor has been diagnosed with class II heart disease and has
    had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should
    anticipate that the primary health care provider most likely prescribe which of the following
    medications?
83. Anticoagulants.
84. Antibiotics.
85. Diuretics.
86. Folic acid supplements.

Answer 82

82. 2. Clients who have been diagnosed with class II heart disease and prosthetic valve
       replacement are most likely to have a prescription for antibiotic medications to prevent the
       development of bacterial endocarditis and bacteremia. Clients with valvular heart disease have a
       high susceptibility to subacute bacterial endocarditis. Anticoagulant therapy is usually discontinued
       during labor and birth because of the potential for hemorrhage. Diuretic medications are generally not
       prescribed for clients with class I or class II heart disease. Diuretics usually are not necessary and
       may result in potassium depletion. Folic acid supplements are usually prescribed for clients with
       megaloblastic anemia. Folic acid is also included in many prenatal vitamins and can help to prevent
       neural tube defects in the fetus.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 83

83. A primigravid client at 39 weeks’ gestation is admitted to the hospital for induction of labor.
    The primary health care provider has prescribed prostaglandin E 2 gel (Dinoprostone) for the client.
    Before administering prostaglandin E 2 gel to the client, which of the following should the nurse do
    first?1. Assess the frequency of uterine contractions.
84. Place the client in a side-lying position.
85. Determine whether the membranes have ruptured.
86. Prepare the client for an amniotomy.

Answer 83

83. 1. Before administering prostaglandin E2 gel, the nurse would assess the frequency and
       duration of any uterine contractions first, because prostaglandin E2 gel is contraindicated if the client
       is having contractions. If there are no contractions, the client should be placed in a semi-Fowler’s
       position to allow for vaginal insertion of the gel. Although determining whether the client’s
       membranes have ruptured is part of the assessment of any client in labor, it is not specifically related
       to the administration of prostaglandin E2 gel. If the membranes remain intact, an amniotomy may be
       performed once the client begins to dilate and the fetal head is engaged. However, it is not necessary
       for the nurse to prepare the client for this procedure at this time.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 84

84. A multigravid client at 39 weeks’ gestation diagnosed with insulin-dependent diabetes is
    admitted for induction of labor with oxytocin. Which of the following should the nurse include in the
    teaching plan as a possible disadvantage of this procedure?
85. Urinary frequency.
86. Maternal hypoglycemia.
87. Preterm birth.
88. Neonatal jaundice.

Answer 84

84. 4. One of the potential disadvantages of oxytocin induction is neonatal jaundice or
       hyperbilirubinemia. Oxytocin decreases the elimination of bilirubin from the neonate. Other adverse
       effects include maternal hypertension and frontal headache, which disappear when the drug is
       discontinued. The drug has antidiuretic properties that can lead to maternal water intoxication.
       Dangerous effects of this powerful drug include uterine hyperstimulation or tetanic contractions,
       which can result in abruptio placentae and uterine rupture. Urinary frequency, maternal hypoglycemia,
       and preterm birth are not associated with oxytocin administration. Ultrasound procedures are used to
       estimate gestational age to prevent preterm birth. Clients with diabetes commonly give birth before
       term because the placenta begins to deteriorate, which can result in stillbirth.CN: Pharmacological and parenteral therapies; CL: Create

Question 85

85. A primigravida is experiencing a prolonged second stage of labor with a fetus suspected of
    weighing over 4 kg. Which of the following interventions is most important?
86. Preparing for a vacuum-assisted birth.
87. Administering an IV fluid bolus.
88. Preparing for an emergency cesarean birth.
89. Performing the McRoberts maneuver.

Answer 85

85. 4. A prolonged second stage of labor with a large fetus could indicate a shoulder dystocia at
       birth. Immediate nursing actions for a shoulder dystocia include suprapubic pressure and the
       McRoberts maneuver. If after interventions for vaginal birth with a shoulder dystocia fail, an
       emergency cesarean birth may be needed but is not indicated at this time. A vacuum-assisted birth
       would be contraindicated due to increased risk of shoulder dystocia with a macrosomic infant. An IV
       fluid bolus may be indicated for fetal distress, but there is not enough information to establish that
       they are needed at this time.
       CN: Physiologic adaptation; CL: Apply

Question 86

86. A multigravid client is receiving oxytocin augmentation. When the client’s cervix is dilated to
    6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which of the
    following actions should the nurse do first?
87. Increase the rate of the oxytocin infusion.
88. Turn the client to a knee-to-chest position.
89. Assess cervical dilation and effacement.
90. Monitor the fetal heart rate continuously.

Answer 86

86. 4. A common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is
       meconium-stained fluid. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is
       necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal
       distress caused by cord prolapse. If there are increasing signs of fetal distress (eg, late
       decelerations), the primary health care provider should be notified immediately. A cesarean birth may
       be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal
       distress. Turning the client to the left side, rather than a knee-chest position, improves placental
       perfusion. The primary health care provider may wish to determine the extent of cervical dilation to
       make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate
       monitoring is essential to determine fetal status.
       CN: Reduction of risk potential; CL: Synthesize

Question 87

87. A multigravid client in active labor at 39 weeks’ gestation has a history of smoking one to
    two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the
    client’s neonate?
88. Sedation.
89. Hyperbilirubinemia.
90. Low birth weight.
91. Hypocalcemia.

Answer 87

87. 3. Neonates born to mothers who smoke tend to have lower-than-average birth weights.
       Neonates born to mothers who smoke also are at higher risk for stillbirth, sudden infant death
       syndrome, bronchitis, allergies, delayed growth and development, and polycythemia. Maternal
       smoking is not related to higher neonatal sedation, hyperbilirubinemia, or hypocalcemia. Smoking
       may cause irritability, not sedation. Hyperbilirubinemia is associated with Rh or ABO
       incompatibility or the administration of intravenous oxytocin during labor. Approximately 50% of
       neonates born to mothers with insulin-dependent diabetes experience hypocalcemia during the first 3
       days of life.
       CN: Health promotion and maintenance; CL: Analyze

Question 88

88. A primigravid client who has had a prolonged labor but now is completely dilated has
    received epidural anesthesia. Which of the following should the nurse include in the teaching plan
    about pushing?
89. The client needs to push for at least 1 to 3 minutes.
90. Pushing is most effective when the client holds her breath.
91. The client should be urged to push with an open glottis.
92. Pushing is limited to times when she feels the urge.

Answer 88

88. 3. The client should be urged to push with an open glottis to prevent the Valsalva maneuver.
       Pushing with a closed glottis increases intrathoracic pressure, preventing venous return. Blood
       pressure also falls, and cardiac output decreases. Pushing for at least 1 to 3 minutes is too long;
       prolonged pushing can lead to reduced blood flow and fatigue. Pushing for the duration of the
       contraction is sufficient. Pushing while holding the breath results in the Valsalva maneuver. Because
       the client has had an epidural anesthetic, she may not feel the urge to push and may need coaching
       during the pushing phase.
       CN: Pharmacological and parenteral therapies; CL: Create

Question 89

89. The primary health care provider determines that outlet forceps are needed to assist in the
    birth of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse
    reinforces the primary health care provider’s explanation for using forceps based on the understanding
    about which of the following concerning the location of the fetal skull?1. It is engaged past the inlet.
90. It is at +1 station.
91. It is visible at the perineal floor.
92. It has reached the level of the ischial spines.

Answer 89

89. 3. When the fetal skull is on the perineum with the scalp visible at the perineal floor or
       vaginal opening, this is considered outlet forceps application. When the head is higher in the pelvis
       but engaged and its greatest diameter has passed the inlet, the operation is termed midforceps.
       Midforceps births are not recommended because they are extremely dangerous for the mother and
       fetus because of the possibility of uterine rupture. If the head is not engaged, at –1 station, this istermed high forceps. High forceps births also are exceedingly dangerous for both the mother and fetus
       because of the possibility of uterine rupture and are not recommended. Cesarean birth is preferred in
       these situations. The fetal head at station +2 or lower is termed low forceps.
       CN: Reduction of risk potential; CL: Apply

Question 90

90. The primary health care provider prescribes an amnioinfusion for a primigravid client at term
    who is diagnosed with oligohydramnios. Which of the following should the nurse include in the
    client’s teaching plan about the purpose of this procedure?
91. To decrease the frequency and severity of variable decelerations.
92. To minimize the possibility of fetal metabolic alkalosis.
93. To increase the fetal heart rate accelerations during a contraction.
94. To raise the amniotic fluid index to more than 15 cm.

Answer 90

90. 1. Oligohydramnios, or a decrease in the volume of amniotic fluid, is associated with variable
       fetal heart rate decelerations due to cord compression. Maintenance of an adequate amniotic fluid
       volume during labor provides protective cushioning of the umbilical cord and minimizes cord
       compression. Cord compression can result in fetal metabolic acidosis, not alkalosis. Amnioinfusion
       is used to minimize cord compression, not to increase the fetal heart rate accelerations during a
       contraction. The goal is to maintain the amniotic fluid index at 8 cm. This can be determined by
       ultrasound.
       CN: Reduction of risk potential; CL: Apply

Question 91

91. The nurse is admitting a primigravid client at 37 weeks’ gestation who has been diagnosed
    with preeclampsia to the labor and birth area. Which of the following client care rooms is most
    appropriate for this client?
92. A brightly lit private room at the end of the hall from the nurses’ station.
93. A semiprivate room midway down the hall from the nurses’ station.
94. A private room with many windows that is near the operating room.
95. A darkened private room as close to the nurses’ station as possible.

Answer 91

91. 4. A primigravid client diagnosed with preeclampsia has the potential for developing seizures
       (eclampsia). This client should be in a room with the least amount of stimulation possible to reduce
       the risk of seizures and as close to the nurses’ station as possible in case the client requires immediate
       assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risk of seizures, as
       can being in a semiprivate room with roommate, visitors, conversation, and noise.
       CN: Management of care; CL: Synthesize

Question 92

92. A multigravid client is admitted to the labor area from the emergency room. At the time of
    admission, the fetal head is crowning, and the client yells, “The baby’s coming!” To help the client
    remain calm and cooperative during the imminent birth, which of the following responses by the nurse
    is most appropriate?
93. “You’re right; the baby is coming, so just relax.”
94. “Please don’t push because you’ll tear your cervix.”
95. “Your doctor will be here as soon as possible.”
96. “I’ll explain what’s happening to guide you as we go along.”

Answer 92

92. 4. The client is experiencing a precipitous birth. The nurse should remain calm during a
       precipitous birth. Explaining to the client what is happening as the birth progresses and how she can
       assist is likely to help her remain calm and cooperative. Maintaining eye contact is also beneficial.
       Telling the client that she is right and to just relax is inappropriate because the client may not be able
       to relax because of the strong urge to push the fetus out of the birth canal. Telling the client not to push
       because she may tear the cervix can instill fear, not cooperation. Saying that the primary health care
       provider will be there soon may not be an accurate statement and is not reassuring if the client is
       concerned about the birth.
       CN: Psychosocial integrity; CL: Apply

Question 93

93. The nurse is caring for a multigravid client who speaks only a foreign language. As the nurse
    enters the client’s room, the nurse observes the client squatting on the bed and the fetal head crowning.
    After calling for assistance and helping the client lie down, which of the following actions should the
    nurse do next?
94. Tell the client to push between contractions.
95. Provide gentle support to the fetal head.
96. Apply gentle upward traction on the neonate’s anterior shoulder.
97. Massage the perineum to stretch the perineal tissues.

Answer 93

93. 2. During a precipitous birth, after calling for assistance and helping the client lie down, the
       nurse should provide support to the fetal head to prevent it from coming out. It is not appropriate to
       tell the client to push between contractions because this may lead to lacerations. The shoulder should
       be delivered by applying downward traction until the anterior shoulder appears fully at the introitus,
       then upward pressure to lift out the other shoulder. Priority should be given to safe birth of the infant
       over protecting the perineum by massage.
       CN: Reduction of risk potential; CL: Synthesize

Question 94

94. During the first hour after a precipitous birth, the nurse should monitor a multiparous client
    for signs and symptoms of which of the following?
95. Postpartum “blues.”
96. Uterine atony.
97. Intrauterine infection.
98. Urinary tract infection.

Answer 94

94. 2. Because birth occurs so rapidly and the fetus is propelled quickly through the birth canal,
       the major complication of a precipitous birth is a boggy fundus, or uterine atony. The neonate should
       be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital
       setting, the primary health care provider will probably prescribe administration of oxytocin. The
       nurse should gently massage the fundus to ensure that it is firm. There is no relationship between a
       precipitous birth and postpartum “blues” or intrauterine infection. Postpartum “blues” usually do not
       occur until about 3 days postpartum, and symptoms of postpartum infection usually occur after the
       first 24 hours. There is no relationship between a precipitous birth and urinary tract infection eventhough the birth has been accomplished under clean rather than sterile technique. Symptoms of urinary
       tract infection typically begin on the first or second postpartum day.
       CN: Reduction of risk potential; CL: Analyze

Question 95

95. A multigravid client in labor at 38 weeks’ gestation has been diagnosed with Rh sensitization
    and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on themonitor, which of the following patterns is most likely?
96. Early deceleration pattern.
97. Sinusoidal pattern.
98. Variable deceleration pattern.
99. Late deceleration pattern.

Answer 95

95. 2. The fetal heart rate of a multipara diagnosed with Rh sensitization and probable fetal
       hydrops and anemia will most likely demonstrate a sinusoidal pattern that resembles a sine wave. It
       has been hypothesized that this pattern reflects an absence of autonomic nervous control over the fetal
       heart rate resulting from severe hypoxia. This client will most likely require a cesarean birth to
       improve the fetal outcome. Early decelerations are associated with head compression; variable
       decelerations are associated with cord compression; and late decelerations are associated with poor
       placental perfusion.
       CN: Reduction of risk potential; CL: Analyze

Question 96

96. The nurse in the labor and birth area receives a telephone call from the emergency room
    announcing that a multigravid client in active labor is being transferred to the labor area. The client
    has had no prenatal care. When the client arrives by stretcher, she says, “I think the baby’s coming …
    Help!” The fetal skull is crowning. The nurse should obtain which of the following information first?
97. Estimated date of birth.
98. Amniotic fluid status.
99. Gravida and parity.
100. Prenatal history.

Answer 96

96. 1. A priority assessment for the nurse to make is to determine the estimated date of childbirth
       or probable gestational age of the fetus. If the gestation is less than 37 weeks, the neonatal team
       should be called to begin resuscitative efforts if needed. Amniotic fluid status is not important at this
       point, because if the fetal skull is crowning, birth is imminent. Determination of gravida and parity is
       part of the normal nursing history, but the priority is the status of the fetus and safe birth. Prenatal
       history is part of the nursing assessment, but this information is not especially relevant until the fetus
       is safely born and has been given immediate care.
       CN: Health promotion and maintenance; CL: Analyze

Question 97

97. A multiparous client gives birth to dizygotic twins at 37 weeks’ gestation. The twin neonates
    require additional hospitalization after the client is discharged. In planning the family’s care, an
    appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will
    do which of the following?
98. Discuss how they will cope with twin infants at home.
99. Participate in care of the twins as much as possible.
100. Take turns providing 24-hour observation of the twins.
101. Identify complications that may occur as the twins develop.

Answer 97

97. 2. It is important that the parents be allowed to touch, hold, and participate in care of the twins
       whenever they desire. Ideally, this will be on a daily basis, to promote parent-infant bonding. It is not
       appropriate to discuss how the couple will cope with twin infants at home until they are ready to take
       the infants home. They are too overwhelmed at this point and are focused on the well-being of their
       infants while hospitalized. Having the couple visit the twins to provide care on a 24-hour basis is not
       warranted. Identifying complications that may occur is not appropriate. If complications arise, the
       parents should be well informed and given opportunities for discussion related to the care provided.
       CN: Psychosocial integrity; CL: Create

Question 98

98. A primigravid client at 41 weeks’ gestation is admitted to the hospital’s labor and birth unit in
    active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a
    healthy neonate vaginally with a midline episiotomy. Which of the following problems should the
    nurse identify as the priority for the client?
99. Activity intolerance.
100. Sleep deprivation.
101. Situational low self-esteem.
102. Risk for infection.

Answer 98

98. 4. Birth trauma and prolonged ruptured membranes make risk for infection the priority
       problem for this client. Infection can be a serious postpartum complication. Although the client may
       be fatigued, she should not be experiencing activity intolerance. Clients with heart disease may
       experience activity intolerance due to excessive cardiac workload. Although the client may be
       experiencing sleep deprivation, most clients are alert and awake after birth of a neonate. Situational
       low self-esteem is not a priority. Clients who undergo a cesarean birth commonly feel a sense of
       failure because of not having a vaginal birth experience, but this is not the case for this client.
       CN: Reduction of risk potential; CL: Analyze

Question 99

99. The nurse is caring for a primiparous client and her neonate immediately after birth. The
    neonate was born at 41 weeks’ gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms
    of which of the following conditions should be a priority in this neonate?
100. Anemia.
101. Hypoglycemia.
102. Delayed meconium.
103. Elevated bilirubin.

Answer 99

99. 2. Postmature neonates commonly have difficulty maintaining adequate glucose reserves and
       usually develop hypoglycemia soon after birth. Other common problems include meconium aspiration
       syndrome, polycythemia, congenital anomalies, seizure activity, and cold stress. These complications
       result primarily from a combination of advanced gestational age, placental insufficiency, and
       continued exposure to amniotic fluid. Delayed meconium is not associated with postterm gestation.
       Hyperbilirubinemia occurs in term neonates as well as postterm neonates, but unless there is an Rh
       incompatibility it does not develop until after the first 24 hours of life.CN: Reduction of risk potential; CL: Analyze

Question 100

100. A multigravid client in active labor at term is diagnosed with polyhydramnios. The primary
     health care provider has instructed the client about possible neonatal complications related to the
     polyhydramnios. The nurse determines that the client has understood the instructions when the client
     states that polyhydramnios is associated with which of the following in the fetus or neonate?
101. Renal dysfunction.
102. Intrauterine growth retardation.
103. Pulmonary hypoplasia.4. Gastrointestinal disorders.

Answer 100

100. 4. Polyhydramnios is an abnormally large amount of amniotic fluid in the uterus. The client
        has understood the instructions when the client states that polyhydramnios is associated with
        gastrointestinal disorders (eg, tracheoesophageal fistula). Polyhydramnios is also associated with
        maternal illnesses such as diabetes and anemia. Other fetal/neonatal disorders associated with this
        condition include congenital anomalies of the central nervous system (eg, anencephaly), upper
        gastrointestinal obstruction, and macrosomia. Polyhydramnios can lead to preterm labor, premature
        rupture of the membranes, and cord prolapse. Renal dysfunction and intrauterine growth retardation
        are associated with oligohydramnios, not polyhydramnios. Pulmonary hypoplasia (poorly developed
        lungs) is associated with prolonged oligohydramnios.
        CN: Reduction of risk potential; CL: Evaluate

Question 101

101. A primigravid client at 39 weeks’ gestation is admitted to the hospital in active labor. On
     admission, the client’s cervix is 6 cm dilated. After 2 hours of active labor, the client’s cervix is still
     dilated at 6 cm with 100% effacement at +1 station. Contractions are 3 to 5 minutes apart, lasting 45
     seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing
     which of the following?
102. Cephalopelvic disproportion.
103. Prolonged latent phase.
104. Prolonged transitional phase.
105. Hypotonic contraction pattern.

Answer 101

101. 1. If a client has been in active labor and there is no change in cervical dilation after 2 hours,
        the nurse should suspect cephalopelvic disproportion. This may be caused by an inadequate pelvis
        size of the mother or by a large-for-gestational-age fetus. The primary health care provider should be
        notified about the client’s lack of progress. If the fetus cannot descend, a cesarean birth is warranted.
        The client is not experiencing a prolonged latent phase (0 to 3 cm dilation), because her cervix is
        dilated to 6 cm. She has not reached the transitional phase, characterized by a cervical dilation of 8 to
        10 cm. With a hypotonic labor pattern, contractions are painful but far apart and not very intense. This
        client’s contractions are of moderate intensity.
        CN: Reduction of risk potential; CL: Analyze

Question 102

102. The primary health care provider who elects to perform a cesarean birth on a primigravid
     client for fetal distress has informed the client of possible risks during the procedure. When the nurse
     asks the client to sign the consent form, the client’s husband says, “I’ll sign it for her. She’s too upset
     by what is happening to make this decision.” The nurse should:
103. Ask the client if this is acceptable to her.
104. Have the client and her husband both sign the consent form.
105. Ask the client to sign the consent form.
106. Ask the doctor to witness the consent form.

Answer 102

102. 3. Preparation for cesarean birth is similar to preparation for any abdominal surgery. The
        client must give informed consent. Another person may not sign for the client unless the client is
        unable to sign the form. If this is the case, only certain designated people can do so legally. The
        husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery
        may be performed without a written consent if it is done to save the life of the mother or the child, or
        both.
        CN: Management of care; CL: Synthesize

Question 103

103. A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal
     birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm
     dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse
     observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the
     decreased variability is most likely caused by which of the following?
104. Maternal fatigue.
105. Fetal malposition.
106. Small-for-gestational-age fetus.
107. Effects of analgesic medication.

Answer 103

103. 4. Decreased variability may be seen in various conditions. However, it is most commonly
        caused by analgesic administration. Other factors that can cause decreased variability include
        anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and
        arrhythmias. Maternal fatigue, fetal malposition, and small-for-gestational-age fetus are not commonly
        associated with decreased variability.
        CN: Health promotion and maintenance; CL: Apply

Question 104

104. During a scheduled cesarean birth of a primigravid client with a fetus at 39 weeks’ gestation
     in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the
     client that the neonatologist is present because neonates born by cesarean birth tend to have an
     increased incidence of which of the following?
105. Congenital anomalies.
106. Pulmonary hypertension.
107. Meconium aspiration syndrome.
108. Respiratory distress syndrome.

Answer 104

104. 4. Respiratory distress syndrome is more common in neonates born by cesarean section than
        in those born vaginally. During a vaginal birth, pressure is exerted on the fetal chest, which aids in the
        fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with
        a cesarean birth. Congenital anomalies are not more common with cesarean birth. Pulmonary
        hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital
        diaphragmatic hernia, respiratory distress syndrome, or neonatal sepsis, not with cesarean birth.
        Meconium aspiration syndrome occurs more commonly with vaginal birth, postterm neonate, and
        prolonged labor, not with cesarean birth.CN: Health promotion and maintenance; CL: Apply

Question 105

105. A 28-year-old multigravid client at 28 weeks’ gestation diagnosed with acute pyelonephritis
     is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the
     aggressive therapy, the nurse determines that the client needs further instruction when she says that
     acute pyelonephritis can lead to which of the following?
106. Preterm labor.
107. Maternal sepsis.
108. Intrauterine growth retardation.
109. Congenital fetal anomalies.

Answer 105

105. 4. Congenital anomalies are not related to maternal urinary tract infections. A multigravid
        client with acute pyelonephritis is susceptible to preterm labor, premature rupture of the membranes,
        maternal sepsis, intrauterine growth retardation, and fetal loss. The most common organism
        responsible for the urinary tract infection is Escherichia coli.
        CN: Reduction of risk potential; CL: Evaluate

Question 106

106. A primigravid client at 38 weeks’ gestation is admitted to the labor suite in active labor. The
     client’s physical assessment reveals a chlamydial infection. The nurse explains that if the infection is
     left untreated, the neonate may develop which of the following?
107. Conjunctivitis.
108. Heart disease.
109. Harlequin sign.
110. Brain damage.

Answer 106

106. 1. Conjunctivitis is a common complication of neonates who are born to mothers with
        untreated chlamydial infection. Neonatal pneumonia is another condition associated with chlamydial
        infection of the mother. Untreated chlamydial infection is not associated with heart disease or brain
        damage. Exposure to rubella may lead to neonatal heart defects, and brain damage may occur as a
        result of prolonged shoulder dystocia or difficulty delivering the fetal head during a vaginal breech
        birth. Occasionally, because of immature circulation, a neonate who has been lying on his or her side
        appears red on one side of the body. This “harlequin sign” is transient and is of no clinical
        significance. Presence of a harlequin sign is unrelated to untreated chlamydial infection.
        CN: Reduction of risk potential; CL: Apply

Question 107

107. A 34-year-old primigravid client at 39 weeks’ gestation admitted to the hospital in active
     labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh
     positive, the client will receive an Rh immune globulin (RHIG) injection for which of the following
     reasons?
108. To prevent Rh-positive sensitization with the next pregnancy.
109. To provide active antibody protection for this pregnancy.
110. To decrease the amount of Rh-negative sensitization for the next pregnancy.
111. To destroy fetal Rh-positive cells during the next pregnancy.

Answer 107

107. 1. The purpose of the RhoGAM is to provide passive antibody immunity and prevent Rh-
        positive sensitization with the next pregnancy. It should be given within 72 hours after birth of an Rh-
        positive neonate. Clients who are Rh-negative and conceive an Rh-negative fetus do not need
        antibody protection. Rh-positive cells contribute to sensitization, not Rh-negative cells. The
        RhoGAM does not cross the placenta and destroy fetal Rh-positive cells.
        CN: Reduction of risk potential; CL: Apply

Question 108

108. A 16-year-old primigravid client admitted at 38 weeks’ gestation with severe preeclampsia
     is given intravenous magnesium sulfate and lactated Ringer’s solution. The nurse should obtain which
     of the following information?
109. Urinary output every 8 hours.
110. Deep tendon reflexes every 4 hours.
111. Respiratory rate every hour.
112. Blood pressure every 6 hours.

Answer 108

108. 3. Because magnesium sulfate is a central nervous system depressant, the nurse should plan
        to assess the client’s respiratory rate every hour. If the respiratory rate is <12 breaths/min, the client
        may be experiencing magnesium sulfate overdose. Urinary output via an indwelling catheter should be
        assessed hourly and should be at least 30 mL/h. Deep tendon reflexes and blood pressure should also
        be assessed every hour. At some institutions continuous electronic blood pressure monitoring will be
        performed.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 109

109. The labor and birth room nurse has received a telephone call from the emergency room
     indicating that a multigravid client in early labor and diagnosed with probable placenta previa will
     be arriving soon. In preparation for the client’s arrival, the nurse anticipates that the primary health
     care provider will prescribe which of the following?
110. Whole blood replacement.
111. Continuous blood pressure monitoring.
112. Internal fetal heart rate monitoring.
113. An immediate cesarean birth.

Answer 109

109. 2. For a client diagnosed with probable placenta previa, hypovolemic shock is a
        complication. Continuous blood pressure monitoring with an electronic cuff is the priority assessment
        after the client’s admission. Once the client is admitted, an ultrasound examination will be performed
        to determine the placement of the placenta. Whole blood replacement is not warranted at this time.
        However, it may be necessary if the client demonstrates signs and symptoms of hemorrhage or shock.
        Internal fetal heart rate monitoring is contraindicated because the monitoring device may puncture the
        placenta and place both the mother and fetus in jeopardy. An immediate cesarean birth is not
        necessary until there has been an assessment of the amount of bleeding and the location of the placenta
        previa.
        CN: Reduction of risk potential; CL: Apply

Question 110

110. During admission, a multigravida in early active labor acts somewhat euphoric and tells the
     nurse that she smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate
     assessment, the nurse should monitor the client for symptoms of which of the following?
111. Placenta previa.
112. Ruptured uterus.
113. Maternal hypotension.
114. Abruptio placentae.

Answer 110

110. 4. Dramatic vasoconstriction occurs as a result of sniffing crack cocaine. This can lead to
        increased respiratory and cardiac rates and hypertension. It can severely compromise placental
        circulation, resulting in abruptio placentae and preterm labor and birth. Infants of these women canexperience intracranial hemorrhage and withdrawal symptoms of tremulousness, irritability, and
        rigidity. Placenta previa, ruptured uterus, and maternal hypotension are not associated with cocaine
        use. Placenta previa may be associated with grand multiparity. Ruptured uterus may be associated
        with a large-for-gestational-age fetus.
        CN: Reduction of risk potential; CL: Analyze

Question 111

111. A primigravid client in early labor tells the nurse that she was exposed to rubella at about
     14 weeks’ gestation. After birth, the nurse should assess the neonate for which of the following?
112. Hydrocephaly.
113. Cardiac disorders.
114. Renal disorders.
115. Bulging fontanels.

Answer 111

111. 2. Pregnant women who become infected with the rubella virus early in pregnancy risk
        having a neonate born with rubella syndrome. The symptoms include thrombocytopenia, cataracts,
        cardiac disorders, deafness, microcephaly, and motor and cognitive impairment. The most extensive
        neonatal effects occur when the mother is exposed during the first 2 to 6 weeks and up to 12 weeks’
        gestation, when critical organs are forming. Bulging fontanels are associated with increased
        intracranial pressure and meningitis, which can occur as the result of a b-hemolytic streptococcal
        infection.
        CN: Reduction of risk potential; CL: Analyze

Question 112

112. A primigravid client in early labor with abruptio placentae develops disseminated
     intravascular coagulation (DIC). Which of the following should the nurse expect the primary health
     care provider to prescribe?
113. Magnesium sulfate.
114. Warfarin sodium (Coumadin).
115. Fresh-frozen platelets.
116. Meperidine hydrochloride (Demerol).

Answer 112

112. 3. To stop the process of DIC, the underlying insult that began the phenomenon must be
        halted. Treatment includes fresh-frozen platelets or blood administration. The primary health care
        provider also may prescribe heparin before the administration of blood products to restore the normal
        clotting mechanism. Immediate birth of the fetus is essential. Magnesium sulfate is given for
        pregnancy-induced hypertension or preterm labor. Heparin, not warfarin sodium (Coumadin), is used
        to treat DIC. Meperidine hydrochloride (Demerol) is used for pain relief.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 113

113. A multigravid client diagnosed with chronic hypertension is now in preterm labor at 34
     weeks’ gestation. The primary health care provider has prescribed magnesium sulfate at 3 g/h. Which
     assessment finding indicates that the intended therapeutic effect has occurred?
114. Decrease in fetal heart rate accelerations.
115. Decrease in the frequency and number of contractions.
116. Decrease in maternal blood pressure rate.
117. Decrease in maternal respiratory rate.

Answer 113

113. 2. The intended effect for this client is to decrease the number and frequency of contractions.
        Even though this client has chronic hypertension, the first goal is to prevent childbirth in a 34 weeks’
        gestation client. If the blood pressure moves into the therapeutic range, that is a benefit for the client
        but it is not the major goal. Magnesium sulfate may decrease the accelerations found in this fetus as it
        decreases the ability of the infant to respond, acting on the infant in the same way it does on the
        mother. Maternal respiratory rate may also decrease, and a lower respiratory rate to 12
        respirations/minute indicates that this level of magnesium sulfate is becoming toxic to this client.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 114

114. A primigravid client who was successfully treated for preterm labor at 30 weeks’ gestation
     had a history of mild hyperthyroidism before becoming pregnant. The nurse should instruct the client
     to do which of the following?
115. Continue taking low-dose oral propylthiouracil as prescribed.
116. Discontinue taking the methimazole until after the birth of the neonate.
117. Consider breast-feeding the neonate after the birth.
118. Contact the primary health care provider if bradycardia occurs.

Answer 114

114. 1. Although thioamides such as propylthiouracil and methimazole are considered teratogenic
        to the fetus and can lead to congenital hyperthyroidism (goiter) in the neonate, they still represent the
        treatment of choice. The client should be regulated on the lowest possible dose. Hyperthyroidism is
        associated with preterm labor and a low-birth-weight infant, so the client should contact the primary
        health care provider if the contractions begin again. The client should not be urged to breast-feed,
        because medications such as propylthiouracil and methimazole are secreted in breast milk.
        Tachycardia (not bradycardia) is associated with thyroid storm, a medical emergency, and should be
        reported to the primary health care provider.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 115

115. A primigravid client at 37 weeks’ gestation has been hospitalized for several days with
     severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to
     have a seizure. Which of the following actions should the nurse do first?
116. Pad the side rails of the client’s bed.
117. Turn the client to the right side.
118. Insert a padded tongue blade into the client’s mouth.
119. Call for immediate assistance in the client’s room.

Answer 115

115. 4. The first action by the nurse should be to call for immediate assistance in the client’s
        room, because this is an emergency. Throughout the seizure, the nurse should note the time and length
        of the seizure and continue to monitor the status of both client and fetus. The side rails should have
        been padded at the time of the client’s admission to the hospital as part of seizure precautions. The
        client should be turned to her left side to improve placental perfusion. Inserting a tongue blade is notrecommended because it can further obstruct the airway or cause injury to the client’s teeth.
        CN: Safety and infection control; CL: Synthesize

Question 116

116. While assessing a primigravid client admitted at 36 weeks’ gestation, the nurse observes
     multiple bruises on the client’s face, neck, and abdomen. When asked about the bruises, the client
     admits that her boyfriend beats her now and then and says, “I want to leave him because I’m afraid he
     will hurt the baby.” Which of the following actions is the nurse’s most appropriate response?
117. Tell the client to leave the boyfriend immediately.
118. Ask the client when she last felt the baby move.
119. Refer the client to a social worker for possible options.
120. Report the incident to the unit nursing supervisor.

Answer 116

116. 3. In an abusive situation, the client’s safety is the priority. The nurse should refer the client
        to a social worker who can provide the client with options such as a safe shelter. Commonly clients
        who are battered feel powerless and fear that the batterer will kill them. As a result, they remain in
        the abusive situation. Telling the client to leave the boyfriend immediately is not helpful and reflects
        the values of the nurse. Although asking about fetal movement is important and is part of a routine
        assessment, a sonogram can be performed to confirm fetal well-being. The referral is more important
        at this time. Although it may be part of the unit’s policies and procedures to report any incidents such
        as this one to the unit supervisor, the client’s immediate need for safety must be addressed first.
        CN: Management of care; CL: Apply

Question 117

117. A multigravid client in active labor at term suddenly sits up and says, “I can’t breathe! My
     chest hurts really bad!” The client’s skin begins to turn a dusky gray color. After calling for
     assistance, which of the following should the nurse do next?
118. Administer oxygen by face mask.
119. Begin cardiopulmonary resuscitation.
120. Administer intravenous oxytocin.4. Obtain a prescription for intravenous fibrinogen.

Answer 117

117. 1. The client’s symptoms are indicative of amniotic fluid embolism, which is a medical
        emergency. After calling for assistance, the first action should be to administer oxygen by face mask
        or cannula to ensure adequate oxygenation of mother and fetus. If the client needs cardiopulmonary
        resuscitation, this can be started once oxygen has been administered. If the client survives,
        disseminated intravascular coagulation will probably develop, and the client will need intravenous
        fibrinogen and heparin. Oxytocin, a vasoconstrictor, is not warranted for amniotic fluid embolism.
        CN: Physiological adaptation; CL: Synthesize

Question 118

Managing Care Quality and Safety

118. The nurse is working on a busy labor and birth unit with other nurses and a licensed
     practical nurse. Which of the following labor clients would the nurse assign to the licensed practical
     nurse?
119. A G 4, P 3 client with a history of gestational diabetes.
120. A G 3, P 1, Ab 1 client at 35 weeks’ gestation.
121. A G 1, P 0 client with leaking green amniotic fluid.
122. A G 2, P 1 client with a history of hyperemesis gravidarum.

Answer 118

Managing Care Quality and Safety
118. 4. Delegation of duties and clients to ancillary personnel is commonly the responsibility of
the registered nurse. The client who is a G 2, P 1, with a history of hyperemesis gravidarum, is the
client with the least potential for labor complications. Hyperemesis gravidarum typically occurs and
is treated in the first or second trimester of pregnancy and should be resolved by this point in the
pregnancy. A G 4, P 3 client with a history of gestational diabetes may have cephalopelvic
disproportion due to a large-for-gestational-age fetus requiring a cesarean section. The G 3, P 1, Ab 1
client is preterm at 35 weeks’ gestation and may require an intensive care neonatal team. In a G 1, P 0
client, leaking green amniotic fluid indicates that there has been fetal distress.
CN: Management of care; CL: Synthesize

Question 119

119. A newly postpartum client is asking to go to the bathroom 45 minutes after childbirth. She
     had an epidural for labor and birth, has an IV infusing, and every 15 minutes assessments are in
     progress. To provide the safest care for this client the nurse should:
120. Ask her to remain in bed until the 15-minute assessments are complete.
121. Assess client’s ability to stand and bear weight before going to the bathroom.
122. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
123. Ask the client to ambulate the first time with a staff member at her side.

Answer 119

119. 2. The nurse will need to assess the client’s ability to bear weight before taking her to the
        bathroom. If she cannot bear weight, she will be unable to ambulate. Asking the client to remain in
        bed until the assessments are complete sets the client up for increased postpartum bleeding, as the
        bladder will displace the uterus. Encouraging the client to sit at the bedside is an excellent strategy to
        prevent orthostatic hypotension, but will not give the nurse an idea if the client can ambulate. Having
        a staff member with the client is also correct for the first ambulation of this client, but the ability to
        bear weight and walk will need to be assessed first.
        CN: Reduction of risk potential; CL: Synthesize

Question 120

120. The charge nurse is preparing for the day shift on the labor and birth unit. Which of the
     following would be included in the responsibilities for this position? Select all that apply.
121. Review the current status of each labor client with the primary nurse.
122. Admit the new labor client sent from the triage area.
123. Complete the work of the nurse who had to leave 30 minutes early.
124. Follow up with the primary nurse after a birth.
125. Complete report of unit with the oncoming charge nurse.

Answer 120

120. 1,4,5. In most settings, the charge nurse coordinates and directs the activities of the unit.
     Prior to the change of shift, the nurse will review and update the status of each of the laboring clients
     on the unit to include any difficulties or unusual situations that may be occurring with each of them,
     including following up with a primary nurse after a birth. A change-of-shift report with the oncoming
     charge nurse is among the last activities completed before ending the shift. Activities such asadmitting a client in labor and completing the nursing responsibilities of the nurse who had to leave
     30 minutes early can be delegated to staff members. In an emergency, the charge nurse could assume
     responsibility for client care.
     CN: Management of care; CL: Create

Question 121

121. The labor and birth nurse is assigned to triage for the day. There are four clients already in
     rooms and the following reports have been received about each of these clients. To provide the safest
     care and best manage time, the nurse should plan to see which client first?
122. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
123. A primipara who is 100% effaced, 8 cm dilated, +2 station with nausea.
124. A client with no prenatal care, occasional contractions, BP 148/90, c/o and swollen feet.
125. A client who is at 42 weeks’ gestation with bloody show, no contractions, ROM 1 hour ago
     leaking green fluid.

Answer 121

121. 4. The client at 42 weeks’ is the greatest concern and the nurse should make rounds on this
        client first based on the length of the pregnancy and the green color of the amniotic fluid. Bloody
        show is a normal sign of impending labor as the cervix may be beginning to dilate. Not having
        contractions after rupture of membranes is not unusual within a 1-hour time frame. The green amniotic
        fluid indicates that fetal distress has recently occurred to the point that the fetus had a bowel
        movement in utero. Along with the 42-week gestation, this fetus is at greatest risk. The nurse can see
        the primipara in active labor at 5 cm dilation last; this client is in pain but nothing about her situation
        indicates anything but a normal labor process and as a primipara, her labor process will be slow. The
        client that is completely effaced, 8 cm dilated and at +2 station as a primipara usually moves through
        labor at a slower pace than a multiparous client. She is experiencing nausea that is an expected
        situation as a laboring client enters transition. The client with no prenatal care is a cause for concern
        as the nurse knows nothing about her background. Her blood pressure is elevated, an indicator of
        mild preeclampsia, but there is no other indications of worsening preeclampsia, such as headache,
        visual disturbances, or epigastric pain.
        CN: Management of care; CL: Synthesize

Question 122

122. The triage nurse is giving a telephone report to the receiving nurse in the labor and birth
     unit. The client is a G4 P3 who is 8 cm dilated and is being transferred to the labor and birth unit.
     How should the labor and birth nurse manage the next ten minutes with the client? Select all that
     apply.
123. Place client on the fetal and contraction monitor.
124. Call other staff to set up the birthing table.
125. Assess comfort needs of client.
126. Determine support systems for client.
127. Prepare to give an early report to the nurse arriving on the next shift.

Answer 122

122. 1,2,3,4. Assuring the safety of this client is the top priority. The nurse should place the client
     on the fetal and contraction monitor. Since the client is 8 cm dilated and a multigravid client, asking
     other staff members to set up the birthing table would be in order. This client is not a candidate for
     medication as this may have an influence on the baby. This client is past the point of offering an
     epidural as she may have given birth by the time the medication is in effect, but comfort measures
     such as warm or cool cloths, back rubs, etc. may be helpful. The support system is an important
     aspect of the birthing process and is an easily settled situation. Preparing to give an early report to the
     oncoming nurse does not apply in this situation.
     CN: Management of care; CL: Create

Question 123

123. A client has experienced a postpartum hemorrhage. The primary health care provider
     verbally ordered carboprost tromethamine (Hemabate) 0.25 mg IM stat at the time of the hemorrhageand this was given by the nurse. The primary health care provider put a prescription into the
     electronic medical record for 0.25 mg carboprost tromethamine IV stat. When seeing the prescription,
     how should the nurse administering the carboprost tromethamine respond?
124. Ask the charge nurse to have a discussion with the primary health care provider about the
     prescription.
125. Initiate an incident report.
126. Call the primary health care provider, discuss the prescription, and request revision if heard
     correctly.
127. Wait until the primary health care provider returns to the unit and discuss the situation in
     person.

Answer 123

123. 3. In emergency situations, verbal prescriptions should be entered into the electronic medical
        record or chart and signed immediately after the emergency. The nurse taking this prescription and
        giving the medication needs to call the primary health care provider, explain the prescription and that
        the medication was administered per the verbal prescription, and request that the primary health care
        provider write the correct prescription. If the nurse misunderstood the prescription and gave the
        medication by the wrong route, an incident report will need to be initiated. The charge nurse would
        become involved if an error has occurred, an incident report is needed, or there is difficulty between
        the nurse and primary health care provider that cannot be remediated. Rectifying this prescription is
        the responsibility of the implementing nurse. Waiting until the primary health care provider comes
        back to the hospital unit may not occur quickly enough to safely care for the client.
        CN: Management of care; CL: Synthesize

Question 124

124. The nurse is asked to develop an in-service to explain documents guiding professional
     nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The
     nurse correctly explains that the Code of Ethics asks nurses to demonstrate which of the following?
     Select all that apply.
125. Maintain the integrity of practice and shape social policy.
126. Develop, maintain, and improve health care environments.
127. Ask the hospital systems for fair compensation for work.
128. Be responsible and accountable for individual practice.
129. Increase professional competence and personal growth.

Answer 124

124. 1,2,4,5. The Code of Ethics describes those actions by the nurse that guide their practice. It
     is the responsibility of each nurse to be active in determining policy for health care for all citizens
     and assuring that the way nursing is practiced is of the highest caliber. Nursing needs to participate inthe development of health care of the future, such as the EMR (electronic medical record), while
     caring for all members of society. In order to be productive in shaping policy, nurses need to be
     politically astute while growing personally and professionally to meet the needs of patients. The
     Code of Ethics does not address compensation for work.
     CN: Management of care; CL: Apply