Rasmussen College: NUR 2513 Exam 1 Study Guide Questions, LATEST 2021/2022,100% CORRECT

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Rasmussen College: NUR 2513Exam 1 Study Guide Questions¬¬¬, LATEST 2021/2022 While the vital signs of a pregnant client in her third trimester are being assessed, the client complains of feeling... faint, dizzy, and agitated. Which nursing intervention is appropriate? a. Have the stand up and retake her blood pressure. b. Have client the client sit down and hold her arm in a dependent position. c. Have the client turn to her left side and recheck her blood pressure in 5 minutes. d. Have the client lie supine for 5 minutes and recheck her blood pressure on both arms. Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension. 2 A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider? a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. b. These conditions are abnormal. Refer the client to an ear, nose, and throat specialist. c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds. As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy. Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone levels increase during pregnancy. The client should be reassured that these symptoms are within normal limits. No referral is needed at this time. Relaxation of the smooth muscles in the respiratory tract is affected by progesterone. 3 Which suggestion is appropriate for the pregnant client who is experiencing heartburn? a. Drink plenty of fluids at bedtime. b. Eat only three meals a day so the stomach is empty between meals. c. Drink coffee or orange juice immediately on arising in the morning. d. Use Tums or Alkamints to obtain relief, as directed by the health care provider. Antacids high in calcium (e.g., Tums, Alkamints) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the woman to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach. 4 While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions? a. These contractions may indicate preterm labor. b. These are contractions that never cause any discomfort. c. Braxton Hicks contractions only start during the third trimester. d. These occur throughout pregnancy, but you may not feel them until the third trimester. Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy. 5 What is the reason for vascular volume increasing by 40% to 60% during pregnancy? a. Prevents maternal and fetal dehydration b. Eliminates metabolic wastes of the mother c. Provides adequate perfusion of the placenta d. Compensates for decreased renal plasma flow The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy. 6 Physiologic anemia often occurs during pregnancy because of: a. inadequate intake of iron. b. the fetus establishing iron stores. c. dilution of hemoglobin concentration. d. decreased production of erythrocytes. When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy. 7 A client is currently pregnant; she has a 5-year-old son and a 3-year-old daughter. She had one other pregnancy that terminated at 8 weeks. Which are her gravida and para? a. 3, 2 b. 4, 3 c. 4, 2 d. 3, 3 She has had four pregnancies, including the current one (gravida 4). She had two pregnancies that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she is classified as a gravida 4. Gravida 4 is correct, but she is para 2; the pregnancy that was terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she would be classified as a gravida 4, not 3. 8 A client’s last menstrual period was June 10. What is her estimated date of birth (EDD)? a. April 7 b. March 17 c. March 27 d. April 17 To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 3 months (March 10), and adds 7 days (March 17). April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of adding 7 days. March is the correct month, but instead of adding 7 days, 17 days were added. April 17 is subtracting 2 months instead of 3. 9 Why should a woman in her first trimester of pregnancy expect to visit her health care provider every 4 weeks? a. Problems can be eliminated. b. She develops trust in the health care team. c. Her questions about labor can be answered. d. The conditions of the expectant mother and fetus can be monitored. This routine allows for monitoring maternal health and fetal growth and ensures that problems will be identified early. All problems cannot be eliminated because of prenatal visits, but they can be identified. Developing a trusting relationship should be established during these visits, but that is not the primary reason. Most women do not have questions concerning labor until the last trimester of the pregnancy. 10 A client in her first trimester complains of nausea and vomiting. She asks, “Why does this happen?” What is the nurse’s best response? a. “It is due to an increase in gastric motility.” b. “It may be due to changes in hormones.” c. “It is related to an increase in glucose levels.” d. “It is caused by a decrease in gastric secretions.” Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause of nausea and vomiting. 11 A client notices that the health care provider writes “positive Chadwick’s sign” on her chart. She asks the nurse what this means. Which is the nurse’s best response? a. “It means the cervix is softening.” b. “That refers to a positive sign of pregnancy.” c. “It refers to the bluish color of the cervix in pregnancy.” d. “The doctor was able to flex the uterus against the cervix.” 12 Which is the gravida and para for a client who delivered triplets 2 years ago and is now pregnant again? a. 2, 3 b. 1, 2 c. 2, 1 d. 1, 3 She has had two pregnancies (gravida 2); para refers to the outcome of the pregnancy rather than the number of infants from that pregnancy. She is pregnant now, so that would make her a gravida 2. She is para 1 because she had one pregnancy that progressed to the age of viability. 13 To relieve a leg cramp, what should the client be instructed to perform? a. Dorsiflex the foot. b. Apply a warm pack. c. Stretch and point the toe. d. Massage the affected muscle. 14 Which complaint made by a client at 35 weeks of gestation requires additional assessment? a. Abdominal pain b. Ankle edema in the afternoon c. Backache with prolonged standing d. Shortness of breath when climbing stairs Abdominal pain may indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae. Ankle edema in the afternoon is a normal finding at this stage of the pregnancy. Backaches while standing is a normal finding in the later stage of pregnancy. Shortness of breath is an expected finding at 35 weeks. 15 A pregnant woman is the mother of two children. Her first pregnancy ended in a stillbirth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the five-digit system to describe this woman’s current obstetric history, what should the nurse record? a. 4-1-2-0-2 b. 3-1-2-0-2 c. 4-2-1-0-1 d. 3-1-1-1-3 Gravida (the first number) is 4 because this woman is now pregnant and was pregnant three times before. Para (the next four numbers) represents the outcomes of the pregnancies and would be described as follows: • T: 1 = term birth at 41 weeks of gestation (son) • P: 2 = preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter) • A: 0 = abortion; none • L: 2 = living children, her son and her daughter She is currently pregnant so she is a gravida 4. She had one term infant, two preterm infants, no abortion, and three living children. 16 Which laboratory result would be a cause for concern if exhibited by a client at her first prenatal visit during the second month of her pregnancy? a. Rubella titer, 1:6 b. Platelets, 300,000/mm3 c. White blood cell count, 6000/mm3 d. Hematocrit 38%, hemoglobin 13 g/dL A rubella titer of less than 1:8 indicates a lack of immunity to rubella, a viral infection that has the potential to cause teratogenic effects on fetal development. Arrangements should be made to administer the rubella vaccine after birth during the postpartum period because administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women receiving the vaccine during the postpartum period should be cautioned to avoid pregnancy for 3 months. The lab values for WBCs, platelets, and hematocrit/hemoglobin are within the expected range for pregnant women. 17 A client in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse give about safe travel during pregnancy? a. “Only travel by car during pregnancy.” b. “Avoid use of the seat belt during the third trimester.” c. “You can travel by plane until your 38th week of gestation.” d. “If you are traveling by car stop to walk every 1 to 2 hours.” Car travel is safe during normal pregnancies. Suggest that the woman stop to walk every 1 to 2 hours so she can empty her bladder. Walking also helps decrease the risk of thrombosis that is elevated during pregnancy. Seat belts should be worn throughout the pregnancy. Instruct the woman to fasten the seat belt snugly, with the lap belt under her abdomen and across her thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her uterus. Travel by plane is generally safe up to 36 weeks if there are no complications of the pregnancy, so only travelling by car is an inaccurate statement. 18 The client has just learned she is pregnant and overhears the gynecologist saying that she has a positive Chadwick’s sign. When the client asks the nurse what this means, how should the nurse respond? a. “Chadwick’s sign signifies an increased risk of blood clots in pregnant women because of a congestion of blood.” b. “That sign means the cervix has softened as the result of tissue changes that naturally occur with pregnancy.” c. “This means that a mucous plug has formed in the cervical canal to help protect you from uterine infection.” d. “This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix.” Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and labia. This discoloration, referred to as Chadwick’s sign, is one of the earliest signs of pregnancy. Although Chadwick’s sign occurs with hyperemia (congestion with blood), the sign does not signify an increased risk of blood clots. The softening of the cervix is called Goodell’s sign, not Chadwick’s sign. Although the formation of a mucous plug protects from infection, it is not called Chadwick’s sign. 19 When a pregnant woman develops ptyalism, what should the nurse advise? a. Chew gum or suck on lozenges between meals b. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals. c. Take short walks to stimulate circulation in the legs and elevate the legs periodically. d. Use pillows to support the abdomen and back during sleep. Some women experience ptyalism, or excessive salivation. The cause of ptyalism may be decreased swallowing associated with nausea or stimulation of the salivary glands by the ingestion of starch. Small frequent meals and use of chewing gum and oral lozenges offer limited relief for some women. All other options include recommendations for pregnant women; however, they do not address ptyalism. 20 A pregnant immigrant has an unknown immunization history. When she presents for routine vaccinations, which will the nurse administer? a. Hepatitis B b. Measles c. Rubella d. Varicella In general, immunizations with live virus vaccines (e.g., measles, mumps, rubella, varicella, smallpox) are contraindicated during pregnancy because they may have teratogenic effects on the fetus. Inactivated vaccines are safe and can be used in women who have a risk of developing diseases such as tetanus, hepatitis B, and influenza. 21 When documenting a client encounter, what term will the nurse use to describe the woman who is in the 28th week of her first pregnancy? a. Multigravida b. Multipara c. Nullipara d. Primigravida 22 You are performing assessments for an obstetric client who is 5 months pregnant with her third child. Which finding would cause you to suspect that the client was at risk? a. Client states that she doesn’t feel any Braxton Hicks contractions like she had in her prior pregnancies. b. Fundal height is below the umbilicus. c. Cervical changes, such as Goodell’s sign and Chadwick’s sign, are present. d. She has increased vaginal secretions. Based on gestational age (20 weeks), the fundal height should be at the umbilicus. This finding is abnormal and warrants further investigation about potential risk. With subsequent pregnancies, multiparas may not perceive Braxton Hicks contractions as being evident compared with their initial pregnancy. Cervical changes such as Goodell’s and Chadwick’s signs should be present and are considered a normal finding. Increased vaginal secretions are normal during pregnancy as a result of increased vascularity. 23 What is the best explanation that you can provide to a pregnant client who is concerned that she has “pseudoanemia” of pregnancy? a. Have her write down her concerns and tell her that you will ask the physician to respond once the lab results have been evaluated. b. Tell her that this is a benign self-limiting condition that can be easily corrected by switching to a high-iron diet. c. Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition. d. Contact the physician and get a prescription for iron pills to correct this condition. Providing factual information based on physiologic mechanisms is the best option. Although having the client write down her concerns is reasonable, the nurse should not refer this conversation to the physician but rather address the client’s specific concerns. Switching to a high-iron diet will not correct this condition. This physiologic pattern occurs during pregnancy as a result of hemodilution from excess blood volume. Iron medication is not indicated for correction of this condition. There is no need to contact the physician for a prescription. 24 Which physiologic finding is consistent with normal pregnancy? a. Systemic vascular resistance increases as blood pressure decreases. b. Cardiac output increases during pregnancy. c. Blood pressure remains consistent independent of position changes. d. Maternal vasoconstriction occurs in response to increased metabolism. Cardiac output increases during pregnancy as a result of increased stroke volume and heart rate. Systemic vascular resistance decreases while blood pressure remains the same. Maternal blood pressure changes in response to client positioning. In response to increased metabolism, maternal vasodilation is seen during pregnancy. 25 A pregnant client complains that since she has been pregnant, her nose is always stuffed and she feels like she has a cold. Past medical history is negative for respiratory problems such as hay fever, sinusitis, or other allergies. What is the most likely cause for the client’s presentation? a. Increased effects of progesterone to maintain the pregnancy b. Effects of estrogen on the respiratory tract c. Development of allergies as a result of pregnancy because of altered immunity d. Increase in fluid consumption during pregnancy leading to overhydration Increasing estrogen levels during pregnancy can affect the respiratory tract passages, leading to increased vascular responses that manifest as coldlike symptoms. Progesterone, as the hormone of pregnancy, maintains the pregnancy and does not have any direct effects on the maternal respiratory passages. Although it is possible for a client to develop allergies based on exposure to antigen triggers, it is not typically associated with pregnancy states. An increase in fluid may lead to potential edema, but it is not associated with coldlike symptoms. 26 A pregnant client complains of frequent heartburn. The client states that she has never had these symptoms before and wonders why this is occurring now. The best response that the nurse can provide is: a. examine her dietary intake pattern and tell her to avoid certain foods. b. tell her that this is a normal finding during early pregnancy and will resolve as she gets closer to term. c. explain to the client that physiologic changes caused by the pregnancy make her more likely to experience these types of symptoms. d. refer her to her health care provider for additional testing because this is an abnormal finding. The presentation of heartburn is a normal abnormal finding that can occur in pregnant woman because of relaxation of the lower esophageal sphincter as a result of the physiologic effects of pregnancy. Although foods may contribute to the heartburn, the client is asking why this presentation is occurring, so the nurse should address the cause first. It is independent of gestation. There is no need to refer to the physician at this time because this is a normal abnormal finding. There is no evidence of complications ensuing from this presentation. 27 Which physiologic event may lead to increased constipation during pregnancy? a. Increased emptying time in the intestines b. Abdominal distention and bloating c. Decreased absorption of water d. Decreased motility in the intestines Decreased motility in the intestines leading to increased water absorption would cause constipation. Increased emptying time in the intestines leads to increased nutrient absorption. Abdominal distention and bloating are a result of increased emptying time in the intestines. Decreased absorption of water would not cause constipation. 28 Which physiologic findings are seen with respect to gallbladder function that might lead to the development of gallstones during pregnancy? a. Decrease in alkaline phosphatase levels compared with nonpregnant women b. Increase in albumin and total protein as a result of hemodilution c. Hypertonicity of gallbladder tissue d. Prolonged emptying time Prolonged emptying time is seen during pregnancy and may lead to the development of gallstones. In pregnancy, there is a twofold to fourfold time increase in alkaline phosphatase levels as compared with those in nonpregnant woman. During pregnancy, a decrease in albumin level and total protein are seen as a result of hemodilution. Gallbladder tissue becomes hypotonic during pregnancy. 29 Which of these findings would indicate a potential complication related to renal function during pregnancy? a. Increase in glomerular filtration rate (GFR) b. Increase in serum creatinine level c. Decrease in blood urea nitrogen (BUN) d. Mild proteinuria With pregnancy, one would expect the serum creatinine and BUN levels to decrease. An elevation in the serum creatinine level should be investigated. With pregnancy, the GFR increases because of increased renal blood flow and is thus a normal expected finding. A decrease in the blood urea nitrogen level and mild proteinuria are expected findings in pregnancy. 30 A pregnant client notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products as a cleansing solution or makeup. What would the priority nursing intervention be in response to this situation? a. Refer the client to a dermatologist for further examination. b. Ask the client if she has been eating different types of foods. c. Take a culture swab and send to the lab for culture and sensitivity (C&S). d. Let the client know that this is a common finding that occurs during pregnancy. This condition is known as chloasma or melasma (mask of pregnancy) and is a result of pigmentation changes relative to hormones. It can be exacerbated by exposure to the sun. There is no need to refer to a dermatologist. Intake of foods is not associated with exacerbation of this process. There is no need for a C&S to be taken. The client should be assured that this is a normal finding of pregnancy. 31 Determine the obstetric history of a client in her fifth pregnancy who had two spontaneous abortions in the first trimester, one infant at 32 weeks’ gestation, and one infant at 38 weeks’ gestation. a. G5 T1 P2 A2 L 2 b. G5 T1 P1 A1 L2 c. G5 T0 P2 A2 L2 d. G5 T1 P1 A2 L2 This client is in her fifth pregnancy, which is G5, she had one viable term infant (between 38 and 42 weeks’ gestation), which is T1, she had one viable preterm infant (between 20 and 37 weeks’ gestation), which is P1, two spontaneous abortions (before 20 weeks’ gestation), which is A2, and she has two living children, which is L2. 32 Use Nägele’s rule to determine the EDD (estimated day of birth) for a client whose last menstrual period started on April 12. a. February 19 b. January 19 c. January 21 d. February 7 Nägele’s rule subtracts 3 months from the month of the last menstrual period (month 4 month – 3 = January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days = April 19), so the correct answer is January 19. 33 Which of the client health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy? a. Sexual intercourse two or three times weekly b. Moderate exercise for 30 minutes daily c. Working 40 hours a week as a secretary in a travel agency d. Relaxing in a hot tub for 30 minutes a day, several days a week Pregnant women should avoid activities that might cause hyperthermia. Maternal hyperthermia, particularly during the first trimester, may be associated with fetal anomalies. She should not be in a hot tub for more than 10 minutes at less than 100 F. Sexual intercourse is generally safe for the healthy pregnant woman; moderate exercise during pregnancy can strengthen muscles, reduce backache and stress, and provide a feeling of well-being; working during pregnancy is acceptable as long as the woman is not continually on her feet or exposed to environmental toxins and industrial hazards. 34 A client who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition? a. Congenital anomalies b. Death before or after birth c. Neonatal hypoglycemia d. Neonatal withdrawal syndrome Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight, abruptio placentae, placenta previa, preterm birth, perinatal mortality, and SIDS. Smoking does not appear to cause congenital anomalies, hypoglycemia, or withdrawal syndrome. 35 The patient reports that the first day of her last normal menstrual period was December 8. Using Nägele’s rule, what date will the nurse identify as the estimated date of birth? a. March 1 b. March 15 c. September 1 d. September 15 Nägele’s rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and adding 7 days. The incorrect responses add months instead of subtracting months and subtract days instead of adding days. 36 The client with an IUD has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action? a. A therapeutic abortion will need to be scheduled because fetal damage is inevitable. b. Hormonal analyses will be done to determine the underlying cause of the false-positive test result. c. The IUD will need to be removed to avoid complications such as miscarriage or infection. d. The IUD will need to remain in place to avoid injuring the fetus. Pregnancy with an intrauterine device (IUD) in place is unusual but it can occur and cause complications such as spontaneous abortion and infection. A therapeutic abortion is not indicated unless infection occurs. 37 The health care provider reports that the primigravida’s fundus can be palpated at the umbilicus. Which priority question will the nurse include in the client’s assessment? a. “Have you noticed that it is easier for you to breathe now?” b. “Would you like to hear the baby’s heartbeat for the first time?” c. “Have you felt a fluttering sensation in your lower pelvic area yet?” d. “Have you recently developed any unusual cravings, such as for chalk or dirt?” Quickening is the first maternal sensation of fetal movement and is often described as a fluttering sensation. Quickening is detected at approximately 20 weeks in the primigravida and as early as 16 weeks in the multigravida. The fundus is at the umbilicus at 20 weeks’ gestation. Lightening is associated with descent of the fetal head into the maternal pelvis and is associated with improved lung expansion. Lightening occurs approximately 2 weeks before birth in the primipara. Fetal heart tones can be detected by Doppler as early as 9 to 12 weeks of gestation. Pica is the craving for non-nutritive substances such as chalk, dirt, clay, or sand. It can develop at any time during pregnancy. It can be associated with malnutrition and the health care provider should monitor the client’s hematocrit/hemoglobin, zinc, and iron levels. 38 A patient at 24 week’ gestation reports to the clinic nurse that she is tired all the time. What is the nurse’s best response? a. “Everyone has chronic anemia at this time in pregnancy.” b. “I’ll make sure your health care provider is informed of your concern.” c. “Your urine is clean of protein and sugar. You are doing well at this time.” d. “Make sure you are drinking enough fluid to keep up with the demands of your body.” The patient is experiencing classic signs of physiologic anemia, or an increase in the amount of plasma resulting in a dilution of circulating red blood cells (RBCs). Red blood cell production will continue to increase throughout pregnancy, with a resulting resolution in physiologic anemia. The health care provider will likely order a complete blood count to verify this. The anemia is physiologic and not chronic because there is no decrease in circulating RBCs. The absence of proteinuria and glucosuria is reassuring, but these findings are not correlated with fatigue. Adequate fluid volume intake is essential in pregnancy but is not responsible for the development of physiologic anemia or the corresponding fatigue. 39 A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all of the time. The patient’s urine test is positive for hCG. What is the best nursing action related to this information? a. Ask the patient if she has had any nausea or vomiting in the morning. b. Schedule the patient to be seen by a health care provider within the next 4 weeks. c. Send the patient to the maternity screening area of the clinic for a routine ultrasound. d. Determine if there are any factors that might prohibit her from seeking medical care. The patient has presumptive and probable indications of pregnancy. However, she has not sought out health care until late in the first or early in the second trimester. The nurse must assess for barriers to seeking health care, physical or emotional, because regular prenatal care is key to a positive pregnancy outcome. Asking if the patient has nausea or vomiting will only add to the list of presumptive signs of pregnancy, and this information will not add to the assessment data to determine whether the client is pregnant. The patient needs to see a health care provider before the next 4 weeks because she is late in seeking early prenatal care. Ultrasounds must be prescribed by a health care provider and ordering one is not in the nurse’s scope of practice. 40 A nurse is conducting a prenatal history with a patient who is new to the clinic. The woman reports that she had one healthy baby at term, and a miscarriage at 8 weeks. What will the nurse document as the patient’s GTPAL? a. 21011 b. 20111 c. 30111 d. 31011 Because this is a prenatal history, the client is pregnant. Gravida is the number of times the uterus has been pregnant, which in this case is three. The patient reported one Term birth, no Preterm births, one Abortion or miscarriage, and presumably one Live child. 41 The clinic nurse confirms that a patient is pregnant. She reports to the nurse that she has regular periods, and the first day of her last period was on January 20. Using Nägele’s rule, what due date will the nurse relay to the patient? a. September 23 b. September 27 c. October 23 d. October 27 Nägele’s rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and then adding 7 days. 42 The nurse is scheduling the next appointment for a healthy primigravida currently at 28 weeks gestation. When will the nurse schedule the next prenatal visit? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks From 29 to 36 weeks, routine prenatal assessment is every 2 weeks. If the pregnancy is high risk, the patient will see the health care provider more frequently. 43 The nurse is assessing a patient during a routine prenatal visit. Her pregnancy has been unremarkable, and at her last visit her fundal height measurement was 23 cm. The nurse measures the patient’s fundal height at 24 cm. What is the next nursing action? a. Ask the patient when she last felt fetal movement. b. Palpate the patient’s bladder to determine if it is full. c. Review the patient’s chart for her pattern of weight gain. d. Assess the patient’s deep tendon reflexes (DTRs) bilaterally at the patella. Between 16 and 36 weeks, fundal height measurement corresponds with the weeks of gestation. The patient was last at the clinic at 23 weeks and would be rescheduled to return at 27 week, or in 4 weeks. The fundal height is 3 cm less than it should be, so the nurse is concerned about fetal well-being. Fetal movement is one of the first indicators of fetal well-being. If the patient’s bladder is full, the fundal height measurement will surpass the expected finding. Weight gain can be an indicator of well-being, nutritional status, and excess fluid volume. It is not as reliable an indicator as fetal movement for well-being. DTRs are assessed routinely to assess for hyperreflexia associated with gestational or pregnancy-induced hypertension. 44 A pregnant client reports that she works in a long-term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine. As the nurse, you are aware that some immunizations are safe to administer during pregnancy, whereas others are not. Which vaccines could this client receive? (Select all that apply.) a. Tetanus b. Varicella c. Influenza d. Hepatitis A and B e. Measles, mumps, rubella (MMR) Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe to administer to women who have a risk for contracting or developing the disease. Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus. 45 The nurse is teaching a pregnant client about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? (Select all that apply.) a. Report watery vaginal discharge. b. Report puffiness of the face or around the eyes. c. Report any bloody show when you go into labor. d. Report visual disturbances, such as spots before the eyes. e. Report any dependent edema that occurs at the end of the day. Watery vaginal discharge could mean that the membranes have ruptured. Puffiness of the face or around the eyes and visual disturbances may indicate preeclampsia or eclampsia. These three signs should be reported. Bloody show as labor starts may mean the mucous plug has been expelled. One of the earliest signs of labor may be bloody show, which consists of the mucous plug and a small amount of blood. This is a normal occurrence. Up to 70% of women have dependent edema during pregnancy. This is not a sign of a pregnancy complication. 46 The nurse is planning care for a client in her first trimester of pregnancy who is experiencing nausea and vomiting. Which interventions should the nurse plan to teach this client? (Select all that apply.) a. Suck on hard candy. b. Take prenatal vitamins in the morning. c. Try some herbal tea to relieve the nausea. d. Drink fluids frequently but separate from meals. e. Eat crackers or dry cereal before arising in the morning.. A client experiencing nausea and vomiting should be taught to suck on hard candy, drink fluids frequently but separately from meals, and eat crackers, dry toast, or dry cereal before arising in the morning. Prenatal vitamins should be taken at bedtime because they may increase nausea if taken in the morning. Before taking herbal tea, the client should check with her health care provider. 47 Which are presumptive signs of pregnancy? (Select all that apply.) a. Quickening b. Amenorrhea c. Ballottement d. Goodell’s sign e. Chadwick’s sign Quickening, amenorrhea, and Chadwick’s sign are presumptive signs of pregnancy. Ballottement and Goodell’s sign are probable signs of pregnancy. 48 Which factors contribute to the presence of edema in the pregnant client? (Select all that apply.) a. Diet consisting of processed foods b. Hemoconcentration c. Increase in colloid osmotic pressure d. Last trimester of pregnancy e. Decreased venous return Processed foods, which are high in sodium content, can contribute to edema formation. As the pregnancy progresses, because of the weight of the uterus, compression takes place, leading to decreased venous return and an increase in edema formation. A decrease in colloid osmotic pressure would contribute to edema formation and fluid shifting. Hemodilution would also lead to edema formation. 49 When planning a diet with a pregnant client, what should the nurse’s first action be? a. Teach the client about MyPlate. b. Review the client’s current dietary intake. c. Instruct the client to limit the intake of fatty foods. d. Caution the client to avoid large doses of vitamins, especially those that are fat-soluble. The first action should be to assess the client’s current dietary pattern and practices because instruction should be geared to what she already knows and does. Teaching the food guide MyPlate is important but not the first action when planning a diet with a pregnant client. Limiting intake of fatty foods is important in a pregnant client’s diet but not the first action. Cautioning about excessive fat-soluble vitamins is important but not the first action. 50 A nurse is teaching a nutrition class to a group of pregnant clients. The nurse should include that the major source of nutrients in the diet of a pregnant woman should be composed of which? a. Fats b. Fiber c. Simple sugars d. Complex carbohydrates Complex carbohydrates supply the pregnant woman with vitamins, minerals, and fiber. Fats provide 9 calories in each gram, in contrast to carbohydrates and proteins, which provide only 4 calories in each gram. Fiber is supplied mainly by the complex carbohydrates. The most common simple carbohydrate is table sugar, which is a source of energy but does not provide any nutrients. 51 To increase the absorption of iron in a pregnant client, with what should an iron preparation be given? a. Tea b. Milk c. Coffee d. Orange juice A vitamin C source may increase the absorption of iron. Tannin in the tea reduces the absorption of iron. The calcium and phosphorus in milk decrease iron absorption. Decreased intake of caffeine is recommended during pregnancy. 52When should iron supplementation during a normal pregnancy begin? a. Before pregnancy b. In the first trimester c. In the third trimester d. In the second trimester Vitamin supplements should be prescribed in the second trimester, when the need for iron is increased. Healthy young women do not usually need iron supplementation for their diets. Morning sickness in the first trimester increases the routine side effects of iron supplements. The iron supplements may continue to be prescribed in the third trimester and during the postpartum period. 53 What is the recommended weight gain during pregnancy for a client who begins pregnancy at a normal weight? a. 10 to 15 lb b. 15 to 20 lb c. 20 to 25 lb d. 25 to 35 lb A weight gain of 25 to 35 lb is believed to reduce intrauterine growth restriction that may result from inadequate nutrition, and also allows for variations in individual needs. There is no precise weight gain appropriate for all women. A 10-lb weight gain is not sufficient to meet the needs of the pregnancy. A 15- to 20-lb weight gain is recommended for women who are overweight before the pregnancy. A 20- to 25-lb weight gain is recommended for women who are overweight before the pregnancy. 54A client in her fifth month of pregnancy asks the nurse, “How many more calories should I be eating daily?” What should the nurse’s response be? a. 180 more calories a day b. 340 more calories a day c. 452 more calories a day d. 500 more calories a day The increased nutritional needs of pregnancy can be met with an additional 340 calories per day. 180 calories are not enough to meet the increased nutritional needs of pregnancy. 452 calories are more than the recommended calories for pregnancy. 500 calories are more than the recommended calories for pregnancy. 55 A pregnant client’s diet may not meet her need for folate. What is a good source of this nutrient? a. Chicken b. Cheese c. Potatoes d. Green leafy vegetables Sources of folate include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken is a good source of protein, but poor in folate. Cheese is an excellent source of calcium, but poor in folate. Potatoes contain carbohydrates and vitamins but are poor in folate. 56 A pregnant client asks the nurse if she can double her prenatal vitamin dose because she doesn’t like to eat vegetables. What is the nurse’s response about the danger of taking excessive vitamins? a. Increases caloric intake b. Has toxic effects on the fetus c. Increases absorption of all vitamins d. Promotes development of pregnancy-induced hypertension (PIH) The use of vitamin supplements in addition to food may increase the intake of some nutrients to doses much higher than the recommended amounts. Overdoses of some vitamins have been shown to cause fetal defects. Vitamin supplements do not contain calories. Vitamin supplements do not have better absorption than natural vitamins and minerals. There is no relationship between vitamin supplements and PIH. 57 A nurse is conducting a prenatal nutritional education class for a group of nursing students. Which should the nurse include as the definition of pica? a. Iron deficiency anemia b. Intolerance to milk products c. Ingestion of nonfood substances d. Episodes of anorexia and vomiting The practice of eating substances not normally thought of as food is called pica. Clay, dirt, and solid laundry starch are the substances most commonly ingested. Pica may produce iron deficiency anemia if proper nutrition is decreased. Intolerance to milk products is termed lactose intolerance. Pica is not related to anorexia and vomiting. 58 Which is the common effect of both smoking and cocaine use on the pregnant client? a. Vasoconstriction b. Increased appetite c. Increased metabolism d. Changes in insulin metabolism Both smoking and cocaine use cause vasoconstriction, which results in impaired placental blood flow to the fetus. Smoking and cocaine use do not increase appetite, change insulin metabolism, or increase metabolism. 59 The breastfeeding client whose recommended prepregnancy caloric intake was 2000 calories per day would need how many calories per day to meet her current needs? a. 2300 b. 2500 c. 2750 d. 3000 The increase for a breastfeeding client is 500 calories above her recommended prepregnancy caloric intake. 2300 calories is not enough to meet her needs. 2750 calories may be too many calories and may lead to weight gain. 3000 calories is too many for this client and will lead to weight gain. 60 Which is the most important reason for evaluating the pattern of weight gain in pregnancy? a. Prevents excessive adipose tissue deposits b. Determines cultural influences on the woman’s diet c. Assesses the need to limit caloric intake in obese women d. Identifies potential nutritional problems or complications of pregnancy Deviations from the recommended pattern of weight gain may indicate nutritional problems or developing complications. Excessive adipose tissue may occur with excess weight gain but is not the reason for monitoring the weight gain pattern. The pattern of weight gain is not affected by cultural influences. It is important to monitor the pattern of weight gain for the developing complications. 61 A pregnant client would like to know a good food source of calcium other than dairy products. Which is the best answer that the nurse should give? a. Legumes b. Lean meat c. Whole grains d. Yellow vegetables Although dairy products contain the greatest amount of calcium, it can also be found in legumes, nuts, dried fruits, and some dark green leafy vegetables. Lean meats are rich in protein and phosphorus. Whole grains are rich in zinc and magnesium. Yellow vegetables are rich in vitamin A. 62 To determine cultural influences on a client’s diet, what should the nurse do first? a. Evaluate the client’s weight gain during pregnancy. b. Assess the socioeconomic status of the client. c. Discuss the four food groups with the client. d. Identify the food preferences and methods of food preparation common to the client’s culture. Understanding the client’s food preferences and how she prepares food will assist the nurse in determining whether the client’s culture is adversely affecting her nutritional intake. Evaluating a client’s weight gain during pregnancy should be included for all clients, not just for those who are culturally different. The socioeconomic status of the clients may alter the nutritional intake, but not the cultural influence. Teaching the food groups to the client should come after assessing food preferences. 63 Which pregnant adolescent is most at risk for a nutritional deficit during pregnancy? a. A 16-year-old who is 10 lb overweight b. A 17-year-old who is 10 lb underweight c. A 15-year-old of normal height and weight d. A 16-year-old of normal height and weight The adolescent who is pregnant and underweight is most at risk because she is already deficient in nutrition and must now supply the nutritional intake for both herself and her fetus. An overweight pregnant teen is at risk for deficiency but is not at the highest risk. Being underweight is the most risky because she is already deficient. A 15-year-old has special nutritional needs during pregnancy, but she is not at the highest risk for deficiency. A 16-year-old has special nutritional needs during pregnancy, but she is not at the highest risk for deficiency. 64 What should be the goal of a client with the nursing diagnosis “Imbalanced nutrition: Less than body requirements” (related to diet choices inadequate to meet the nutrient requirements of pregnancy)? a. Gain a total of 30 lb. b. Decrease intake of snack foods. c. Take daily supplements consistently. d. Increase intake of complex carbohydrates. A weight gain of 30 lb is one indication that the client has gained a sufficient amount for the nutritional needs of pregnancy. Decreasing snack food may be the problem and should be assessed. However, assessing the weight gain is the best method of monitoring intake for this pregnancy. A daily supplement is not the best goal for this client. It does not meet the basic need of proper nutrition during pregnancy. Increasing the intake of complex carbohydrates is important for this client, but monitoring the weight gain should be the end goal. 65 A client who is in week 28 of gestation is concerned about her weight gain of 17 lb. Which is the nurse’s best response? a. “You should not gain any more weight until you reach the third trimester.” b. “You should try to decrease your amount of weight gain for the next 12 weeks.” c. “You have not gained enough weight for the number of weeks of your pregnancy.” d. “You have gained an appropriate amount for the number of weeks of your pregnancy.” A woman in her 28th week of gestation should have gained between 17 and 20 lb. The normal pattern of weight gain is about 3.5 lb total in the first trimester (by 13 weeks) and 1 lb per week after that. The client has gained the appropriate amount of weight. It would be inappropriate to have her decrease her weight gain. She has gained an appropriate amount of weight and should not increase the weight gain. Weight gain needs to be consistent during the last part of the pregnancy and should not be suppressed. 66 In teaching a pregnant adolescent about nutrition, what should the nurse plan to do? a. Determine the weight gain needed to meet adolescent growth and add 35 lb. b. Suggest that she not eat at fast food restaurants to avoid foods of poor nutritional value. c. Realize that most adolescents are unwilling to make dietary changes during pregnancy. d. Emphasize the need to eliminate common teen snack foods because they are too high in fat and sodium. Adolescents should gain in the upper range of the recommended weight gain. They also need to gain weight that would be expected for their own normal growth. Adolescents are willing to make changes; however, they still need to be like their peers. Eliminating fast foods will make her appear different from her peers. She should be taught to choose foods that add needed nutrients. Changes in the diet should be kept at a minimum and snacks should be included. Snack foods can be included in moderation and other foods added to make up for the lost nutrients 67 The traditional diet of Asian women includes little meat and few dairy products and may be low in calcium and iron. The nurse can help a client increase her intake of these foods by which action? a. Suggest that she eat more tofu, bok choy, and broccoli. b. Suggest that she eat more hot foods during pregnancy. c. Emphasize the need for increased milk intake during pregnancy. d. Tell her husband that she must increase her intake of fruits and vegetables for the baby’s sake. The diet should be improved by increasing foods acceptable to the woman. These foods are common in the Asian diet and are good sources of calcium and iron. Pregnancy is considered hot; therefore, the woman would eat cold foods. Because milk products are not part of this woman’s diet, it should be respected and other alternatives offered. Also, lactose intolerance is common. Fruits and vegetables are cold foods and should be included in the diet. In regard to the family dynamics, however, the husband does not dictate to the wife in this culture. 68 When planning a diet for a pregnant client, which nutritional interventions should be implemented? a. Fluids should be restricted to 6 glasses a day to minimize fluid retention and occurrence of edema. b. Protein in the diet should be increased to meet growth and development needs c. Nutrient density should be used only if there are problems with weight gain during the course of the pregnancy. d. Advise the client that the pattern of weight gain is not as important as the overall weight gained during the pregnancy. An increase in protein consumption is recommended as compared with prepregnancy diet recommendations. Fluid intake should be 8 to 10 glasses per day to maintain hydration. Nutrient density should be used throughout the pregnancy to meet increasing caloric needs. The pattern of weight gain is critical in helping identify potential risks associated with the development of fluid retention and preeclampsia. 69 A pregnant client asks the nurse if she should take herbal supplements during pregnancy. What is the best response to her query? a. “As long as you have had no reaction to them in the past, they would be safe to use during pregnancy.” b. “Prenatal vitamins are the only things that should be taken during pregnancy.” c. “Nutritional supplements will be prescribed by the health care provider based on individual needs.” d. “During pregnancy, no supplementation is required because this is considered to be a healthy state.” 70 Which client would require additional calories and nutrients? a. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy b. An 18-year-old female who delivered a 7-lb baby and is bottle feeding c. A 23-year-old female who had a cesarean section birth and is bottle feeding d. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding A client who is breastfeeding will require more calories and nutrients than individuals who are pregnant, delivered regardless of the type of birth, and whether they are bottle feeding. 71 A client post-delivery is concerned about getting back to her prepregnancy weight. She had only gained 15 pounds during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup? a. Client has lost 35 pounds during the 6-week period prior to her scheduled checkup. b. Client states that she is eating healthy and limiting intake of processed foods. c. Client relates increased consumption of fruits and vegetables in her diet postbirth. d. Client has resumed her usual exercise pattern of walking around the neighborhood for 10 minutes each night. Although a certain amount of weight loss is expected in the postpartum period, the fact that the reported weight loss is double the amount of weight gained during the pregnancy places the client at risk for malnutrition. Further inquiry is needed. Limiting the intake of processed foods is a healthy dietary alternative to decreasing sodium intake. Increases in fruits and vegetables are a healthy dietary alternative to decrease possible occurrence of hypertension. An exercise program is part of a healthy nutrition approach. 72 Which of the following is associated with inadequate maternal weight gain during pregnancy? a. Prolonged labor b. Preeclampsia c. Gestational diabetes d. Low-birth-weight infant Inadequate maternal weight gain during pregnancy can manifest in the birth of a low- birth- weight infant. Prolonged labor and gestational diabetes are associated with excess weight gain during pregnancy. Preeclampsia is based on maternal hypertension, proteinuria, and edema states. 73 A nurse is developing information to give to a group of pregnant women who are interested in nutritional management of their pregnancy with regard to expected weight gain. The nurse bases the amount of weight gain for pregnant women on calculation of their: a. EDC (expected date of confinement). b. prepregnancy weight. c. BMI (body mass index). d. basal energy expenditure (BEE). BMI takes into account height, weight, and body frame characteristics. Weight gain is not based on the EDC. Although the prepregnancy weight is important, it must be looked at in correlation to a calculated BMI. The calculation of BEE is used for clients who are at nutritional risk and are receiving enteral and/or parenteral nutrition therapies. 74 A pregnant client comes to the OB clinic and informs you that she is very concerned about the amount of weight gain associated with pregnancy. She then tells you that she wants to switch to a low-fat diet during pregnancy. BMI measurements indicate a BMI of 22.7. What would be the best nursing response to this client’s stated plan? a. Tell the client that as long as she maintains a varied diet with regard to the other nutrients, there should be no problems. b. Refer the client to a dietician for assistance in planning the low-fat diet. c. Advise the client that it is important to maintain the intake of essential fatty acids during pregnancy. d. Schedule the client for more frequent visits during the next few months to evaluate her weight pattern. t is important to teach the client that essential fatty acids are needed in the diet to assist fetal development (visual and cognitive). Dieting during pregnancy is not advised. Clients should maintain a regular diet that has a varied intake of nutrient sources. There is no need for referral at this time because dieting is not recommended during pregnancy. The client’s BMI indicates that she is within the normal weight range. There is no need to add additional appointments at this time. 75 A pregnant client arrives for her first prenatal visit at the clinic. She tells you that she has been taking an additional 400 mcg of folic acid prior to her pregnancy. Based on information obtained, she is at 8 weeks’ gestation. What recommendation would you give regarding folic acid supplementation? a. Have the client continue to take 400 mcg folic acid throughout her pregnancy. b. Tell the client that she no longer has to take additional folic acid because it will be included in her prenatal vitamins. c. Have the client increase her folic acid intake to 1000 mcg throughout the rest of her pregnancy. d. Schedule the client to go for an AFP (alpha-fetoprotein) test. Prenatal vitamins include adequate folic acid supplementation, so clients should not take additional supplementation as long they continue their prenatal vitamins. During pregnancy, the recommendation is to increase the folic acid intake to 600 mcg. 1000 mcg of folic acid would be an excessive dose. The AFP test should be done at 15 to 18 weeks’ gestation. This is not clinically indicated because the client is at 8 weeks’ gestation. 76 Which food selections would lead to enhanced iron absorption during pregnancy? a. Eating additional fiber and grains in the diet b. Drinking coffee with meals c. Drinking orange juice d. Including spinach in the diet two to three times a week which contains ascorbic acid, acts to enhance iron absorption. Foods that are high in fiber and grains contain phytates, which can decrease iron absorption. Coffee intake can affect iron binding and therefore decrease absorption. Spinach contains oxalates, which can interfere with iron absorption 77 Which client is most at risk for a low-birth-weight infant? a. 22-year-old, 60 inches tall, normal prepregnant weight b. 18-year-old, 64 inches tall, body mass index is <18.5 c. 30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm d. 35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb The client who has a low prepregnancy weight is associated with preterm labor and low- birth- weight infants. Women who are underweight should gain more during pregnancy to meet the needs of pregnancy as well as their own need to gain weight; clients who have a normal prepregnancy weight, who start pregnancy overweight, or who have a history of excessive weight gain in pregnancy are not at risk for low-birth-weight infants. 78 Changes in the diet of the pregnant client who has phenylketonuria would include: a. adding foods high in vitamin C. b. eliminating drinks containing aspartame. c. restricting protein intake to <20 g a day. d. increasing caloric intake to at least 1800 cal/day. Use of aspartame by women with phenylketonuria can result in fetal brain damage because these women lack the enzyme to metabolize aspartame. Adding vitamin C, restricting protein, and increasing caloric intake are not necessary for the pregnant client with phenylketonuria. 79 When explaining the recommended weight gain to your client, the nurse’s teaching should include which statement? a. “All pregnant women need to gain a minimum of 25 to 35 pounds.” b. “The fetus, amniotic fluid, and placenta require 15 pounds of weight gain.” c. “Weigh gain in pregnancy is based on the client’s prepregnant body mass index.” d. “More weight should be gained in the first and second trimesters and less in the third.” Recommendations for weight gain in pregnancy are based on the woman’s prepregnancy weight for her height (body mass index). Depending on the prepregnant weight, recommendation for weight gain may be more or less than 25 to 35 pounds. The combination of the fetus, amniotic fluid, and placenta averages about 11 pounds in the client who has a normal BMI. Less weight should be gained in the first trimester, when the fetus needs fewer nutrients for growth, and more in the third trimester, when fetal growth is accelerated. 80 Identify the appropriate weight gain at 28 weeks’ gestation for a client with a normal BMI (body mass index) before pregnancy. a. 10 pounds b. 19 pounds c. 25 pounds d. 30 pounds The woman with a normal BMI before pregnancy will gain approximately 4.4 pounds during the first trimester and 1 pound per week during the second and third trimesters. At 28 weeks, normal weight gain would be 4 pounds during the first trimester and 15 pounds in the second trimester. Ten pounds at 29 weeks gestation is adequate weight gain. Twenty-five and 30 pounds at 28 weeks is excessive weight gain. 81 Which client has correctly increased her caloric intake from her recommended pregnancy intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months? a. From 1800 to 2200 calories per day b. From 2000 to 2500 calories per day c. From 2200 to 2530 calories per day d. From 2500 to 2730 calories per day The increased calories necessary for breastfeeding are 500, with 330 calories coming from increased caloric intake and 170 calories from maternal stores. An increase of 230 calories is insufficient for breastfeeding. An increase of 400 and 500 calories is above the recommended amount. 82 The pregnant woman of normal weight enters her 13th week of pregnancy. If the client eats and exercises as directed, what will the nurse anticipate as the ongoing weight gain for the remaining trimesters? a. 0.3 pound every week b. 1 pound every week c. 1.8 pounds every week d. 2 pounds every week After the first 12 weeks (first trimester), the pregnant woman should gain 0.35 to 0.5 kg (0.8 to 1 lb) per week for the remainder of the pregnanc 83 A client with a BMI of 32 has a positive pregnancy test. What is the maximum number of pounds that the nurse will advise the client to gain during the pregnancy? a. 20 b. 25 c. 28 d. 40 The weight gain for obese women is 5 to 9 kg (11 to 20 lb). A BMI of 30 or higher categorizes the client as obese. The other options refer to minimal or maximal weight gain for clients in other BMI categories. 84 The pregnant client with significant iron deficiency anemia is prescribed iron supplements. The client confides to the nurse that she can’t take iron because it makes her nauseous. What is the best response by the nurse? a. “Iron will be absorbed more readily if taken with orange juice.” b. “It is important to take this drug regardless of this side effect.” c. “Taking the drug with milk may decrease your symptoms.” d. “Try taking the iron at bedtime on an empty stomach.” Iron taken at bedtime may be easier to tolerate. All the answers are true statements; however, only the option that states that iron taken at bedtime may be easier to tolerate addresses both optimal absorption of iron and alleviation of nausea, which will not be noticeable during sleep. It is true that taking iron with milk will decrease the symptoms, but it will also decrease absorption. 85 What will the nurse advise when providing nutrition education to the pregnant client? a. “Every day you need to have at least 6 ounces of protein from sources such as meat, fish, eggs, beans, nuts, soybean products, and tofu.” b. “High-dose vitamin A supplements will promote optimal vision while preventing a common cause of blindness in neonates.” c. “Meals such as sushi with a cold deli salad made with raw sprouts combine high-fiber foods with protein sources to meet multiple nutritional needs.” d. “Vitamin and mineral supplements can meet your nutrient needs if you have inadequate intake because of nausea or a sensation of fullness.” Protein sources include meat, poultry, fish, eggs, legumes (e.g., beans, peas, lentils), nuts, and soybean products such as tofu. Pregnant women need 6 to 6.5 oz of protein daily. Vitamin A can cause fetal anomalies of the bones, urinary tract, and central nervous system when taken in high doses. Pregnant women should avoid raw fish and foods such as cold deli salads and raw sprouts. Supplements do not generally contain protein and calories and may lack many necessary nutrients; therefore, they cannot serve as food substitutes. 86 For the pregnant client who is a vegan, what combination of foods will the nurse advise to meet the nutritional needs for all essential amino acids? a. Eggs and beans b. Fruits and vegetables c. Grains and legumes d. Vitamin and mineral supplements Combining incomplete plant proteins with other plant foods that have complementary amino acids allows intake of all essential amino acids. Dishes that contain grains (e.g., wheat, rice, corn) and legumes (e.g., garbanzo, navy, kidney, or pinto beans, peas, peanuts) are combinations that provide complete proteins. Eggs are not eaten by vegans. Fruits and vegetables alone will not provide the essential amino acids. Vitamin and mineral supplements do not provide amino acids. 87 A pregnant client has lactose intolerance. What recommendation will the nurse provide to best help the client meet dietary needs for calcium? a. Add foods such as nuts, dried fruit, and broccoli to the diet. b. Consume dairy products but take an over-the-counter anti-gas product. c. Increase the intake of dark leafy vegetables, such as spinach and chard. d. Use powdered milk instead of liquid forms of milk. Calcium is present in legumes, nuts, dried fruits, and broccoli, so these foods can be added to increase calcium intake. Although dark leafy vegetables contain calcium, they also contain oxalates that decrease the availability of calcium. Powdered milk contains lactase, just like the nondehydrated varieties. Milk products can be avoided by those with lactose intolerance because adequate calcium may be obtained from food and supplements. 88 The nurse is reviewing the changes in nutrition related to pregnancy with a 17-year-old who is 12 weeks pregnant. They are specifically focusing on the dairy requirements. What is the nurse’s next action? a. Ask, “Do you like milk, yogurt and cheese?” b. Ask, “How many servings from the dairy group do you eat each day?” c. Tell her, “You need to add no less than 3 cups of dairy-based foods each day.” d. Inform her, “If you do not like to drink milk, you can eat a spinach salad every day” To individualize the patient’s teaching plan, the nurse must first assess the patient’s calcium intake. Then the nurse can modify the instructions for adequate calcium intake, based on the patient’s actual needs. Milk, yogurt, and cheese are calcium-rich foods but are inappropriate for the lactose-intolerant patient. The adolescent pregnant patient requires more daily calcium than the recommendation of 3 cups per day for the adult woman. Spinach is a source of calcium but it also contains oxalates, which decrease calcium availability. 89 The health care provider has recommended an iron supplement for the patient who is 20 weeks pregnant. The nurse is reviewing the recommendation with the patient. What fluid is best for the nurse to recommend when taking an iron supplement? a. 8 ounces of milk b. 8 ounces of water c. 4 ounces of orange juice d. 4 ounces of apple juice Iron absorption is enhanced when taken with a source of vitamin C. Calcium can block the absorption of vitamin C. Water and apple juice to not facilitate or block the absorption of iron. 90 The nurse is reviewing a list of foods high in folic acid with a patient who is considering becoming pregnant. The nurse determines that the patient understands the teaching when the patient states she will include which list of foods in her diet? a. Peaches, yogurt, and tofu b. Strawberries, milk, and tuna c. Asparagus, lemonade, and chicken breast d. Spinach, orange juice, and fortified bran flakes Prepregnant, the recommendation for folic acid is 800 mcg. Foods high in folic acid are dark green leafy vegetables, legumes (beans, peanuts), orange juice, asparagus, spinach, and fortified cereal and pasta. In the United States, folic acid is added to orange juice and wheat-based products. 91 A patient at 8 weeks’ gestation complains to the nurse, “I feel sick almost every morning. And I throw up at least two or three times a week.” What is the nurse’s best advice to the patient? a. “Do you like cheese?” b. “Try eating four meals a day instead of three meals a day.” c. “Try eating peanut butter on whole wheat bread right before going to bed.” d. “If you can eat enough throughout the day, you don’t have to worry about being sick.” Eating a bedtime protein snack helps maintain glucose levels throughout the night. Cheese is high in fat and can aggravate nausea. Small and frequent meals is the recommendation; four meals a day is not frequent enough. Consumption is not the patient’s stated concern—it is the nausea and vomiting. 92 The nurse is teaching a client taking prenatal vitamins how to avoid constipation. Which should the nurse plan to include in the teaching session? (Select all that apply.) a. Advise taking a daily laxative for constipation. b. Recommend a diet high in fruits and vegetables. c. Encourage an increase in fluid consumption during the day. d. Increase the intake of whole grains and whole grain products. e. Suggest increasing the intake of dairy products, especially cheeses. Common sources of dietary fiber include fruits and vegetables (with skins when possible— apples, strawberries, pears, carrots, corn, potatoes with skins, and broccoli), whole grains, and whole grain products—whole wheat bread, bran muffins, bran cereals, oatmeal, brown rice, and whole wheat pasta. Increased intake of fluids can help prevent constipation. A pregnant client should not take a daily laxative unless prescribed by her health care provider. Increased intake of dairy products, especially cheese, can increase constipation. 93 The nurse is teaching a breastfeeding client about substances to avoid while she is breastfeeding. Which substances should the nurse include in the teaching session? (Select all that apply.) a. Caffeine b. Alcohol c. Omega-6 fatty acids d. Appetite suppressants e. Polyunsaturated omega-3 fatty acids Foods high in caffeine should be limited. Infants of mothers who drink more than two or three cups of caffeinated coffee or the equivalent each day may be irritable or have trouble sleeping. Although the relaxing effect of alcohol was once thought to be helpful to the nursing mother, the deleterious effects of alcohol are too important to consider this suggestion appropriate today. An occasional single glass of an alcoholic beverage may not be harmful, but larger amounts may interfere with the milk ejection reflex and may be harmful to the infant. Nursing mothers should avoid appetite suppressants, which may pass into the milk and harm the infant. The long-chain polyunsaturated omega-3 and omega-6 fatty acids are present in human milk. Therefore, they should be included in the mother’s diet during lactation. 94 The nurse is advising a lactose-intolerant pregnant client about calcium intake. Which calcium sources are approximately equivalent to 1 cup of milk? (Select all that apply.) a. 3/4 cup yogurt b. 1 cup of sherbet c. 1 1/4oz of hard cheese d. 1 1/4 cups of ice cream e. 3/4 cup of low-fat cottage cheese Calcium sources approximately equivalent to 1 cup of milk include cup yogurt, oz of hard cheese, and cups of ice cream. It takes 3 cups of sherbet and cups of low-fat cottage cheese to equal the calcium equivalent of 1 cup of milk. 95 The nurse is teaching a pregnant client about food safety during pregnancy and lactation. Which statements by the client indicate she understood the teaching? (Select all that apply.) a. “I will limit my intake of shrimp to 12 oz a week.” b. “I will avoid the soft cheeses made with unpasteurized milk.” c. “I plan to continue to pack my bologna sandwich for lunch.” d. “I am glad I can still go to the sushi bar during my pregnancy.” e. “I will not eat any swordfish or shark while I am pregnant or nursing.” Statements that indicate the client understood the teaching are limiting shrimp to 12 oz a week, avoiding soft cheeses, and not eating any swordfish. A bologna sandwich should be avoided unless it is reheated until steaming hot. Raw or undercooked fish should be avoided. 96 A pregnant client’s biophysical profile score is 8. She asks the nurse to explain the results. What is the nurse’s best response? a. “The test results are within normal limits.” b. “Immediate birth by cesarean birth is being considered.” c. “Further testing will be performed to determine the meaning of this score.” d. “An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.” The normal biophysical score ranges from 8 to 10 points if the amniotic fluid volume is adequate. A normal score allows conservative treatment of high-risk patients. Birth can be delayed if fetal well-being is an issue. Scores less than 4 would be investigated, and birth could be initiated sooner than planned. This score is within normal range, and no further testing is required at this time. The results of the biophysical profile are usually available immediately after the procedure is performed. 97 Which analysis of maternal serum may predict chromosomal abnormalities in the fetus? a. Biophysical profile b. Multiple-marker screening c. Lecithin-to-sphingomyelin ratio d. Blood type and crossmatch of maternal and fetal serum Maternal serum can be analyzed for abnormal levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), inhibin A, and estriol. The multiple-marker screening may predict chromosomal defects in the fetus. The biophysical profile is used to evaluate fetal status during the antepartum period. Five variables are used, but none are concerned with chromosomal problems. The lecithin-to-sphingomyelin ratio is used to determine fetal lung maturity. The blood type and crossmatch will not predict chromosomal defects in the fetus. 98 The clinic nurse is obtaining a health history on a newly pregnant client. Which is an indication for fetal diagnostic procedures if present in the health history? a. Maternal diabetes b. Weight gain of 25 lb c. Maternal age older than 30 d. Previous infant weighing more than 3000 g at birth Diabetes is a risk factor in pregnancy because of possible impairment of placental perfusion. Excessive weight gain is an indication for testing. Normal weight gain is 25 to 35 lb. A maternal age older than 35 years is an indication for testing. Having had another infant weighing more than 4000 g is an indication for testing. 99 When is the most accurate time to determine gestational age through ultrasound? a. First trimester b. Second trimester c. Third trimester d. No difference in accuracy among the trimesters Gestational age determination by ultrasonography is increasingly less accurate after the first trimester. Gestational age determination is best done in the first trimester. There is a difference in trimesters when doing a gestational age ultrasonography. 100 The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which? a. Hemophilia b. Sickle cell anemia c. A neural tube defect d. A normal lecithin-to-sphingomyelin ratio An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter the maternal serum. Hemophilia is a genetic defect and is best detected with chromosomal studies, such as chorionic villus sampling or amniocentesis. Sickle cell anemia is a genetic defect and is best detected with chromosomal studies such as chorionic villus sampling or amniocentesis. L/S ratios are determined with an amniocentesis and are usually done in the third trimester. 101 When is the earliest that chorionic villus sampling can be performed during pregnancy? a. 4 weeks b. 8 weeks c. 10 weeks d. 12 weeks Fetal villus tissue can be obtained as early as 10 weeks of gestation and can be analyzed directly for chromosomal or genetic abnormalities. It is too early to be performed at 4 weeks. It is too early to be performed at 8 weeks. The test should be performed at 12 weeks, but it can be done as early as 10 weeks. 102 On which aspect of fetal diagnostic testing do parents usually place the most importance? a. Safety of the fetus b. Duration of the test c. Cost of the procedure d. Physical discomfort caused by the procedure Although all these are considerations, parents are usually most concerned about the safety of the fetus. Parents are concerned about the duration, but it is not the greatest concern. The cost of the procedure is important to parents, especially those without third-party payers, but is not the greatest concern. Discomfort of the procedure is important, especially for the mother, but is not the greatest concern. 103 The nurse’s role in diagnostic testing is to provide which of the following? a. Advice to the couple b. Information about the tests c. Reassurance about fetal safety d. Assistance with decision making The nurse should provide the couple with all necessary information about a procedure so that the couple can make an informed decision. The nurse’s role is to inform, not to advise. Ensuring fetal safety is not possible with all the diagnostic tests. To offer this is to give false reassurance to the parents. The nurse can inform the couple about potential problems so they can make an informed decision. Decision making should always lie with the couple involved. The nurse should provide information so that the couple can make an informed decision. 104 Which should be considered a contraindication for transcervical chorionic villus sampling? a. Rh-negative mother b. Gestation less than 15 weeks c. Maternal age younger than 35 years d. Positive for group B Streptococcus Maternal infection is a risk with this procedure, and it is contraindicated if the client has an active infection in the cervix, vagina, or pelvic area. This procedure is done between 10 and 12 weeks. This procedure is usually done for women older than 35; however, if the woman is at high risk for fetal anomalies, her age is not a contraindication. The procedure can still be performed; however, Rh sensitization may occur if the mother is Rh-negative. Rho(D) immune globulin can be administered following the procedure. 105 Which nursing intervention is necessary prior to a second-trimester transabdominal ultrasound? a. Perform an abdominal prep. b. Administer a soap suds enema. c. Ensure the client is NPO for 12 hours. d. Instruct the client to drink 1 to 2 quarts of water. When the uterus is still in the pelvis, visualization may be difficult. It is necessary to perform the test when the woman has a full bladder, which provides a window through which the uterus and its contents can be viewed. An abdominal prep is not necessary for this procedure. A soap suds enema is not necessary for this procedure. The client needs a full bladder to elevate the uterus; therefore, being NPO would not be appropriate. 106 Which is the major advantage of chorionic villus sampling over amniocentesis? a. It is not an invasive procedure. b. It does not require a hospital setting. c. It requires less time to obtain results. d. It has less risk of spontaneous abortion. Results from chorionic villus sampling can be known within 24 to 48 hours, whereas results from amniocentesis require 2 to 4 weeks. It is an invasive procedure. The woman has to be in a hospital setting for her and the fetus to be properly assessed during and after the procedure. The risk of an abortion is at the same level for both procedures. 107 What is the purpose of amniocentesis for a client hospitalized at 34 weeks of gestation with pregnancy-induced hypertension? a. Determine if a metabolic disorder is genetic. b. Identify the sex of the fetus. c. Identify abnormal fetal cells. d. Determine fetal lung maturity. During the third trimester, amniocentesis is most often performed to determine fetal lung maturity. In cases of pregnancy-induced hypertension, preterm birth may be necessary because of changes in placental perfusion. The test is done in the early portion of the pregnancy if the metabolic disorder is genetic. Amniocentesis is done early in the pregnancy to do genetic studies and determine the sex. Identification of abnormal cells is done during the early portion of the pregnancy. 108 What does nursing care after amniocentesis include? a. Forcing fluids by mouth b. Monitoring uterine activity c. Placing the client in a supine position for 2 hours d. Applying a pressure dressing to the puncture site A risk with amniocentesis is the onset of spontaneous contractions. Hydration is important, but the woman has not been NPO, so this should not be a problem. The supine position may decrease uterine blood flow; the side-lying position is preferred. Pressure dressings are not necessary. 109 What is the term for a non–stress test in which there are two or more fetal heart rate accelerations of 15 or more bpm with fetal movement in a 20-minute period? a. Positive b. Negative c. Reactive d. Nonreactive The non–stress test (NST) is reactive (normal) when there are two or more fetal heart rate accelerations of at least 15 bpm (each with a duration of at least 15 seconds) in a 20-minute period. A positive result is not used with an NST. The contraction stress test (CST) uses positive as a result term. A negative result is not used with an NST. The CST uses negative as a result term. A nonreactive result means that the heart rate did not accelerate during fetal movement. 110 What is the purpose of initiating contractions in a contraction stress test (CST)? a. Increase placental blood flow. b. Identify fetal acceleration patterns. c. Determine the degree of fetal activity. d. Apply a stressful stimulus to the fetus. The CST involves recording the response of the fetal heart rate to stress induced by uterine contractions. The CST records the fetal response to stress. It does not increase placental blood flow. The NST looks at fetal heart accelerations with fetal movements. The NST and biophysical profiles look at fetal movements. 111 What does a score of 9 on a biophysical profile signify? a. Normal b. Abnormal c. Equivocal d. Nonreactive Five parameters of fetal activity—fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume—are used to determine the biophysical profile. The maximum score is 2 points for each parameter. A score falling between 8 and 10 is considered normal. A score of 4 or less is considered abnormal. Equivocal and nonreactive are not terms used to describe the results of a biophysical profile. 112 Which response by the nurse is most appropriate to the statement, “This test isn’t my idea, but my husband insists?” a. “It’s your decision.” b. “Don’t worry. Everything will be fine.” c. “Why don’t you want to have this test?” d. “You’re concerned about having this test?” The nurse should clarify the statement and assist the client in exploring her feelings about the test. “It’s your decision” is a closed statement and does not encourage the woman to express her feelings. “Don’t worry” is false reassurance and does not deal with the concerns expressed by the woman. The woman may not be able to answer “why” questions. It may also make her defensive. 113 A biophysical profile is performed on a pregnant client. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. What would be the correct interpretation of this test result? a. A score of 10 would indicate that the results are equivocal. b. A score of 8 would indicate normal results. c. A score of 6 would indicate that birth should be considered as a possible treatment option. d. A score of 9 would indicate reassurance. The biophysical profile is used to assess fetal well-being. Five categories of assessment are used in this combination test: fetal monitoring NST, evaluation of FBMs, gross movements, fetal tone, and calculation of the amniotic fluid index (AFI). A maximum of 2 points is used if criteria are met successfully in each category; thus a score in the range of 8 to 10 indicates a normal or reassuring finding. A score of 6 provides equivocal results and further testing or observation is necessary. A score of 4 or less requires immediate intervention, and birth may be warranted. The provided assessments indicate a score of 8 as the only area that has not met the stated criteria in the NST. 114 In preparing a pregnant client for a non–stress test (NST), which of the following should be included in the plan of care? a. Have the client void prior to being placed on the fetal monitor because a full bladder will interfere with results. b. Maintain NPO status prior to testing. c. Position the client for comfort, adjusting the tocotransducer belt to locate fetal heart rate. d. Have an infusion pump prepared with oxytocin per protocol for evaluation. The nurse must adjust the tocotransducer to find the best location to pick up and record the fetal heart rate. Positioning the client for comfort during testing is a prime concern. Although a full bladder may affect client comfort, it will not interfere with testing results. NPO status is not required for an NST. Instead, a pregnant client should maintain her normal nutritional intake to provide energy to herself and the fetus. An infusion pump with oxytocin is required for a contraction stress test (CST). 115 The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result? a. Repeat the test in 1 week so that results can be trended based on this baseline result. b. Contact the health care provider to discuss birth options for the client. c. Send the client out for a meal and repeat the test to confirm that the results are valid. d. Ask the client to perform a fetal kick count assessment for the next 30 minutes and then reassess the client. A positive CST test is an abnormal finding, and the physician should be notified so that birth options can be initiated. A positive CST indicates possible fetal compromise. Intervention should not be delayed by 1 week and results do not have to be trended. Because this is an abnormal result, there is no need to repeat the test. Sending the client out for a meal will delay treatment options and may interfere with possible birth interventions if anesthesia is needed. Fetal kick count assessment is not needed at this time and will further delay treatment interventions for this abnormal result, which indicates fetal compromise. 116 A pregnant client has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the client’s plan of care? a. No further testing is indicated at this time because results are normal. b. Refer to the physician for additional testing. c. Validate the results with the lab facility. d. Repeat the test in 2 weeks and have the client return for her regularly scheduled prenatal visit. Additional genetic testing is indicated to provide the client with treatment options. A positive result on a triple-screen test is considered to be an abnormal finding so the client should be referred to the physician for additional genetic testing. Validation of the test with a lab facility is not necessary because the client provided you with a copy of the test results. There is no need to repeat the clinical test because the findings have already been determined. 117 A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered? a. Magnesium sulfate b. Prostaglandin suppository c. RhoGAM if the client is Rh-negative d. Betamethasone CVS can increase the likelihood of Rh sensitization if a woman in Rh-negative. There is no indication for magnesium sulfate because it is used to stop preterm labor. There is no indication for administration of a prostaglandin suppository. Betamethasone is given to pregnant women in preterm labor to improve fetal lung maturity. 118 Which factor serves as a clinical indicator for a third trimester amniocentesis? a. Sex of the fetus b. Rh isoimmunization c. Placenta previa d. Placental abruption Rh isoimmunization is a clinical indicator for a third-trimester amniocentesis. Although an amniocentesis can determine the sex of the fetus, this is not a primary indication for a third- trimester amniocentesis. Ultrasound imaging would be indicated for evaluation of placenta previa. Ultrasound imaging would be indicated for evaluation of placental abruption. 119 For which client would an L/S ratio of 2:1 potentially be considered to be abnormal? a. A 38-year-old gravida 2, para 1, who is 38 weeks’ gestation b. A 24-year-old gravida 1, para 0, who has diabetes c. A 44-year-old gravida 6, para 5, who is at term d. An 18-year-old gravida 1, para 0, who is in early labor at term Even though an L/S ratio of 2:1 is typically considered to be a normal finding to validate fetal lung maturity prior to 38 weeks’ gestation, the result may not be accurate in determining fetal lung maturity if a client is diabetic. 120 Which complication could occur as a result of percutaneous umbilical blood sampling (PUBS)? a. Postdates pregnancy b. Fetal bradycardia c. Placenta previa d. Uterine rupture PUBS is an invasive test whereby a needle is inserted into the umbilical cord to obtain blood as the basis for diagnostic testing with the guidance of ultrasound technology. The most common complication is fetal bradycardia, which is temporary. PUBS has no effect on extending the gestation of pregnancy, the development of placenta previa, or uterine rupture. 121 A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient’s health care provider. When is the best time for the nurse to schedule the patient’s ultrasound? a. Immediately b. In 2 weeks c. In 4 weeks d. In 6 weeks An embryo can be seen about 5 to 6 weeks after the last menstrual period. At this time the crown-rump length (CRL) of the embryo is the most reliable measure of gestational age. Fetal viability is confirmed by observation of fetal heartbeat, which is visible when the CRL of the embryo is 5 mm. 122 The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. The nurse determines that the patient understands the teaching when she mentions that which fluid will be collected for the initial screening process? a. Urine b. Blood c. Saliva d. Amniotic Initial screening is completed with blood. AFP can be detected in amniotic fluid; however, that procedure is more costly and invasive. Procedures progress from least invasive to most invasive. 123 A patient at 36 weeks gestation is undergoing a non–stress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings? a. NST positive, nonreassuring b. NST negative, reassuring c. NST reactive, reassuring d. NST nonreactive, nonreassuring The presence of at least three accelerations of at least 15 beats, over at least 15 seconds, over a duration of at least 20 minutes, is considered reactive and reassuring. Nonreactive testing reveals no or fewer accelerations over the same or longer period. The NST test is not recorded as positive or negative. 124 Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)? (Select all that apply.) a. Down syndrome b. Molar pregnancy c. Twin gestation d. Incorrect gestational age assessment of a normal fetus—estimation is earlier in the pregnancy e. Threatened abortion Elevated APF levels are seen in multiple gestations, underestimation of fetal age, and threatened abortion. Decreased levels are seen in Down syndrome and a molar pregnancy. 125 Transvaginal ultrasonography is often performed during the first trimester. A 6-week-gestation client expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be necessary to determine which of the following? (Select all that apply.) a. Multifetal gestation b. Bicornuate uterus c. Presence and location of pregnancy d. Amniotic fluid volume e. Presence of ovarian cysts A bicornuate uterus, multifetal gestation, presence of ovarian cysts, and presence and location of pregnancy can be determined by transvaginal ultrasound in the first trimester of pregnancy. This procedure is also used for estimating gestational age, confirming fetal viability, identifying fetal abnormalities or chromosomal defects, and identifying the maternal abnormalities mentioned, as well as fibroids. Amniotic fluid volume is assessed during the second and third trimesters. Conventional ultrasound would be used. 126 A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator (VAS) test. Which should the nurse include in the response? (Select all that apply.) a. The test is invasive. b. The test uses sound to elicit fetal movements. c. The test may confirm nonreactive non–stress test results. d. The test can only be performed if contractions are present. e. Vibroacoustic stimulation can be repeated at 1-minute intervals up to three times. Also referred to as VAS or acoustic stimulation, the vibroacoustic stimulator (similar to an electronic larynx) is applied to the maternal abdomen over the area of the fetal head. Vibration and sound are emitted for up to 3 seconds and may be repeated. A fetus near term responds by increasing the number of gross body movements, which can be easily seen and felt. The procedure can confirm reassuring NST findings and shorten the length of time necessary to obtain NST data. The test is noninvasive and contractions do not need to be present to perform the test. 127 The nurse is instructing a client on how to perform kick counts. Which information should the nurse include in the teaching session? (Select all that apply.) a. Use a clock or timer when performing kick counts. b. Your bladder should be full before performing kick counts. c. Notify your health care provider if you have not felt movement in 24 hours. d. Protocols can provide a structured timetable for concentrating on fetal movements. e. You should lie on your side, place your hands on the largest part of the abdomen, and concentrate on the number of movements felt. The nurse should instruct the client to lie on her side, place her hands on the largest part of her abdomen, and concentrate on fetal movements. She should use a clock or timer and record the number of movements felt during that time. Protocols are not essential but may give the client a more structured timetable for when to concentrate on fetal movements. The bladder does not need to be full for kick counts; it is better to have the client empty her bladder before beginning the assessment of fetal movements. Further evaluation is recommended if the client feels no movements in 12 hours; 24 hours is too long before notifying the health care provider. 128 The nurse is reviewing maternal serum alpha-fetoprotein (MSAFP) results. Which conditions are associated with elevated levels of MSAFP? (Select all that apply.) a. Fetal demise b. Neural tube defects c. Abdominal wall defects d. Chromosomal trisomies e. Gestational trophoblastic disease Elevated levels of AFP may indicate open neural tube defects (e.g., anencephaly, spina bifida), abdominal wall defects (e.g., omphalocele, gastroschisis), or fetal demise. Low levels of AFP may indicate chromosomal trisomies (e.g., Down syndrome, trisomy 21) or gestational trophoblastic disease. 129 The nurse is preparing a client for a non–stress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.) a. Ensure that the client has a full bladder. b. Plan approximately 15 minutes for the test. c. Have the client sit in a recliner with the head elevated 45 degrees. d. Apply electronic monitoring equipment to the client’s abdomen. e. Instruct the client to press an event marker every time she feels fetal movement. The client may be seated in a reclining chair or have her head elevated at least 45 degrees. The nurse applies external electronic monitoring equipment to the client’s abdomen to detect the fetal heart rate and any contractions. The woman may be given an event marker to press each time she senses movement. Before the NST, the client should void and her baseline vital signs should be taken. The NST takes about 40 minutes, allowing for most fetal sleep-wake cycles, although the fetus may show a reassuring pattern more quickly or need more time to awaken and become active. Fifteen minutes would not allow enough time to complete the test. 130 The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that he’s doing now, he could tell her when the contractions are: a. 2 minutes apart. b. at their acme. c. at their increment. d. at their decrement. When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity. 131 The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction? a. Is not significantly affected b. Increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Continues except when placental functions are reduced During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions. 132 The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions? a. Vital signs taken during contractions are not accurate. b. During a contraction, assessing fetal heart rate is the priority. c. Maternal blood flow to the heart is reduced during contractions. d. Maternal circulating blood volume increases temporarily during contractions. During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother’s blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction. 133 Uncontrolled maternal hyperventilation during labor results in: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis. Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis. 134 Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Extension b. Engagement c. Internal rotation d. External rotation Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet. 135 The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by: a. promoting blood flow to the cervix. b. contracting the lower uterine segment. c. enlarging the internal size of the uterus. d. pulling the cervix over the fetus and amniotic sac. Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down. 136 Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have: a. a higher hematocrit. b. increased leukocytes. c. increased blood volume. d. a lower fibrinogen level Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy. 137 The nurse is assessing the duration of a client’s labor contractions. Which action does the nurse implement to assess the duration of labor contractions? a. Assess the strongest intensity of each contraction. b. Assess uterine relaxation between two contractions. c. Assess from the beginning to the end of each contraction. d. Assess from the beginning of one contraction to the beginning of the next. Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions. 138 Which event is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent 139 Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Station b. Flexion c. Descent d. Engagement The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet. 140 An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates: a. lightening. b. breech presentation. c. urinary tract infection. d. onset of Braxton-Hicks contractions. As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy. 141 A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long? a. 50 minutes b.3 1/2 hours c. 6 to 7 hours d. 8 to 10 hours The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 minutes for a nullipara. The transition phase lasts hours for a nullipara. A multipara’s active phase of labor is 6 to 7 hours. 142 A client just delivered a baby by the vaginal route. The client asks the nurse why the baby’s head is not round, but oval. Which explanation should the nurse give to the client? a. This results from molding. b. This results from lightening. c. This results from the fetal lie. d. This results from the fetal presentation. The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet. 143 A client whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta. 144 The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase? a. The client is sociable and excited. b. The client is requesting pain medication. c. The client begins to experience the urge to push. d. The client experiences loss of control and irritability. During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor. 145 A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement? a. The acme b. The interval c. The increment d. The decrement The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends 146 A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with: a. more rapid labor. b. a high risk of infection. c. maternal perineal trauma. d. umbilical cord compression. The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth. 147 The primary difference between the labor of a nullipara and that of a multipara is: a. total duration of labor. b. level of pain experienced. c. amount of cervical dilation. d. sequence of labor mechanisms. Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors. 148 Which maternal factor may inhibit fetal descent? a. A full bladder b. Decreased peristalsis c. Rupture of membranes d. Reduction in internal uterine size A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent. 149 Which assessment finding would cause a concern for a client who had delivered vaginally? a. Estimated blood loss (EBL) of 500 mL during the birth process b. White blood cell count of 28,000 mm3 postbirth c. Client complains of fingers tingling d. Client complains of thirst A client’s complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels. 150 Which clinical findings would be considered to be normal for a preterm fetus during the labor period? a. Baseline tachycardia b. Baseline bradycardia c. Fetal anemia d. Acidosis Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise. 151 On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time? a. Perform a vaginal exam to denote progress. b. Notify the health care provider. c. Initiate parenteral therapy. d. Apply oxygen via nasal cannula at 8 L/min. A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress. 152 An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is: a. onset of irregular contractions. b. cephalic presentation at 0 station. c. bloody mucus drainage from vagina. d. fetal heart tones (FHTs) present in the lower right quadrant. Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening. 153 If a notation on the client’s health record states that the fetal position is LSP, this means that the: a. head is in the right posterior quadrant of the pelvis b. head is in the left anterior quadrant of the pelvis. c. buttocks are in the left posterior quadrant of the pelvis. d. buttocks are in the right upper quadrant of the abdomen LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT. 154 The assessment finding which indicates that the client is in the active phase of the first stage of labor is: a. 80% effacement. b. dilation of 5 cm. c. presence of bloody show. d. regular contraction every 3 to 4 minutes. The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined. 155 To determine if the client is in true labor, the nurse would assess for changes in: a. cervical dilation. b. amount of bloody show. c. fetal position and station. d. pattern of uterine contractions. Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor. 156 The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%/-1. What instruction will the nurse implement with the patient? a. “You will need to remain in bed attached to the electronic fetal monitor. b. “Breathe with me slowly, in through your nose and out through your mouth.” c. “I will begin the administration of 1000 mL of IV fluid so you can have an epidural.” d. “Your partner will need to change into scrub attire to attend the imminent birth.” This client is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the stem that the membranes are ruptured, which may prohibit the patient from ambulating. Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at -1 station. Epidural placement during early labor may slow down the labor process. There is no indication that birth is imminent because the patient is 3 cm dilated. 157 The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient? a. On her back b. On her left side c. On her right side d. On her hands and knees LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus. Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are present, there is no need to implement this position. 158 The primipara at 39 weeks’ gestation states to the nurse, “I can breathe easier now.” What is the nurse’s best response? a. “You labor will start any day now since the baby has dropped.” b. “That process is called lightening. Do you have to urinate more frequently?” c. “Contact your health care provider when your contractions are every 5 minutes for 1 hour.” d. “You will likely not feel you baby’s movements as much now, so do not be concerned.” As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patient’s statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified. 159 The nurse assess a laboring patient’s contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern? a. Stage 1, latent phase b. Stage 2, latent phase c. Stage 1, active phase d. Stage 2, active phase In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage 2, latent phase, the woman is resting and preparing to push; she likely has not experienced the Ferguson reflex. She is actively bearing down during the active phase of the second stage. 160 A laboring patient states to the nurse, “I have to push!” What is the next nursing action? a. Contact the health care provider. b. Examine the patient’s cervix for dilation. c. Review with her how to bear down with contractions. d. Ask her partner to support her head with each push. When the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed. 161 After birth of the placenta the patient states, “All of a sudden I feel very cold.” What is the best nursing action in response to this statement? a. Place a warm blanket over the patient. b. Place the baby on the patient’s abdomen. c. Tell the patient that chills are expected after birth. d. “What do you mean by your words ‘very cold’?” Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary. 162 A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.) a. Ask her if her if she thinks that her membranes have ruptured. b. Ask her if she has any evidence of bloody show. c. Have her keep monitoring her contraction pattern and call you back if they become more regular. d. Ask her when her she has her next scheduled visit with her health care provider. e. Tell her to come into the hospital for evaluation. The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor. 163 A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.) a. In true labor, the cervix begins to dilate. b. In true labor, the contractions are felt in the abdomen and groin. c. In true labor, contractions often resemble menstrual cramps during early labor. d. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages. e. In true labor your contractions tend to increase in frequency, duration, and intensity with walking. In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking. False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in frequency, duration, and intensity. 164 The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.) a. Powers b. Passage c. Position d. Passenger e. Psyche • Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. • Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor. • Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. • Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman’s ability to cope. Position is not one of the four Ps. 165 The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) a. Offer the client a warm blanket. b. Place an ice pack on the perineum. c. Massage the uterus if it is boggy. d. Delay breastfeeding until the client is rested. e. Explain to the client that the lochia will be light pink in color. The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink. 166 Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) a. A gush of blood appears. b. The uterus rises upward in the abdomen. c. The fundus descends below the umbilicus. d. The cord descends further from the vagina. e. The uterus becomes boggy and soft, with an elongated shape. Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected. 167 The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.) a. Progesterone levels become higher than estrogen levels. b. Natural oxytocin in conjunction with other substances plays a role. c. Stretching, pressure, and irritation of the uterus and cervix increase. d. The secretion of prostaglandins from the fetal membranes decreases. Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labor’s initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes. 168 The nurse is preparing to perform Leopold’s maneuvers. Why are Leopold’s maneuvers used by practitioners? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position Leopold’s maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination. 169 Which comfort measure should a nurse use to assist a laboring woman to relax? a. Recommend frequent position changes. b. Palpate her filling bladder every 15 minutes. c. Offer warm wet cloths to use on the client’s face and neck. d. Keep the room lights lit so the client and her coach can see everything. Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights. 170 Which assessment finding could indicate hemorrhage in the postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits. 171 Which is an essential part of nursing care for a laboring client? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Feeling comfortable with the predictable nature of intrapartal care d. Sharing personal experiences regarding labor and birth to decrease her anxiety Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority. 172 A client at 40 weeks’ gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: a. fetal movement. b. irregular contractions for 1 hour. c. a trickle of fluid from the vagina. d. thick pink or dark red vaginal mucus. A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced. 173 Which client at term should go to the hospital or birth center the soonest after labor begins? a. Gravida 2, para 1, who lives 10 minutes away b. Gravida 1, para 0, who lives 40 minutes away c. Gravida 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours. 174 A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are: a. contraction pattern, amount of discomfort, and pregnancy history b. fetal heart rate, maternal vital signs, and the woman’s nearness to birth. c. last food intake, when labor began, and cultural practices the couple desires. d. identification of ruptured membranes, the woman’s gravida and para, and her support person. All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman’s gravida and para, and her support person are assessments that can occur later in the admission process if time permits. 175 A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be: a. discharged home with a sedative. b. admitted for extended observation. c. admitted and prepared for a cesarean birth. d. discharged home to await the onset of true labor. The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated. 176 The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast. The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR. 177 Which should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. 178 The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications. 179 Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth? a. Bloody mucous discharge increases. b. The vulva bulges and encircles the fetal head. c. The membranes rupture during a contraction. d. The fetal head is felt at 0 station during the vaginal examination. A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. 180 During labor a vaginal examination should be performed only when necessary because of the risk of: a. infection. b. fetal injury. c. discomfort. d. perineal trauma. Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma. 181 A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband’s hand away and shouts, “Don’t touch me!” This behavior is most likely: a. abnormal labor. b. a sign that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor. The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis. 182 At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant’s trunk is pink, but the hands and feet are blue. The Apgar score for this infant is: a. 7. b. 8. c. 9. d. 10. The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant’s blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant’s hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant’s hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet. 183 If a woman’s fundus is soft 30 minutes after birth, the nurse’s first response should be to: a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position. The nurse’s first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding. 184 The nurse thoroughly dries the infant immediately after birth primarily to: a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface. Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood. 185 The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior. d. Determine whether the mother is too fatigued to interact normally with her infant. Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner. 186 Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth. 187 Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor? a. Length of second-stage labor is 2 hours. b. Client has received an epidural for pain control during the labor process. c. Client is using breathing techniques during contractions to maximize pain relief. d. Client is receiving parenteral fluids during the course of labor to maintain hydration. A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit. 188 A gravida 1, para 0, 38 weeks’ gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time? a. Performing more frequent vaginal exams will not make the labor go any quicker. b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c. Tell the client that she will check every 30 minutes. d. Medicate the client as needed for anxiety so that the labor can progress. Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client’s anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth. 189 When using the second Leopold’s maneuver in fetal assessment, the nurse would palpate (the): a. both sides of the maternal abdomen. b. lower abdomen above the symphysis pubis. c. both upper quadrants of the maternal abdomen . d. lower abdomen for flexion of the presenting part. The second Leopold’s maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver. 190 A nursing priority during admission of a laboring client who has not had prenatal care is: a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care. When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient’s history has been completed. 191 The nurse has given the newborn an Apgar score of 5. She should then: a. begin ventilation and compressions. b. do nothing except place the infant under a radiant warmer. c. observe the infant and recheck the score after 10 minutes. d. gently stimulate by rubbing the infant’s back while administering O2. An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborn’s transition to extrauterine life. 192 The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client’s record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine d. The client’s understanding of the event Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client’s understanding of the event would only need to be documented if it presents a problem. 193 At 5 minutes after birth, the nurse assesses that the neonate’s heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a. 7 b. 8 c. 9 d. 10 The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8. 194 The gynecologist performs an amniotomy. What will the nurse’s role include immediately following the procedure? a. Assessing for ballottement b. Conducting a pH and/or fern test c. Labeling of specimens for chromosomal analysis d. Recording the character and amount of amniotic fluid An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis. 195 The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation. 196 The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time? a. To apply internal monitoring electrodes b. To assess for Goodell’s sign c. To determine cervical dilation and effacement d. To determine strength of contractions The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodell’s sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions. 197 A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a. Obtain a fetal heart rate. b. Determine the estimated due date. c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat. On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed. 198 The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse’s priority action with this procedure? a. Perform Leopold’s maneuvers. b. Determine the color of the amniotic fluid. c. Assess the fetal heart rate immediately after the procedure. d. Prepare the patient for a change in her pain level after the procedure. An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopold’s maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor. 199 The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a. 18-gauge b. 20-gauge c. 22-gauge d. 24-gauge The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula 200 The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a. Place the catheter as quickly as possible. b. Place a small pillow under the patient’s left hip. c. Omit the use of a cleansing agent, such as Betadine. d. Set up the catheter tray before positioning the patient. To promote placental function, the nurse can place a small pillow or rolled blanket under the patient’s left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care. 201 The nurse examines a primipara’s cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse’s priority action? a. Palpate her bladder for fullness. b. Assess the frequency and duration of her contractions. c. Determine who will stay with the patient for the birth. d. Encourage the patient to exhale in short breaths with contractions. Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient’s urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push. 202 The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby’s head? a. Expulsion b. Restitution c. Internal rotation d. External rotation After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head. 203 A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time d. Faster descent of the fetus e. An increase in frequency of contractions Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body’s signals. A brief slowing of contractions often occurs at the beginning of the second stage. 204 Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant’s head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed. Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant’s head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period. 205 When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.) a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor. Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth. 206 Which interventions are required following an amniotomy procedure? (Select all that apply.) a. Notation related to amount of fluid expelled b. Color and consistency of fluid c. Fetal heart rate d. Maternal blood pressure e. Maternal heart rate Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required. 207 The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a. Maternal hypotension b. Fetal heart rate of 140 to 150 bpm c. Meconium-stained amniotic fluid d. Maternal fever—38° C (100.4° F) or higher e. Complete uterine relaxation of more than 30 seconds between contractions Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38° C [100.4° F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding. 208 The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a. Soft boggy uterus b. Maternal temperature of 99° F c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics e. Half of a lochia pad saturated in the first hour after birth Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts. 209 The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? a. This pattern reflects variable decelerations. No interventions are necessary at this time. b. Document this reassuring fetal heart rate pattern but decrease the rate of the intravenous (IV) fluid. c. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. d. This deceleration pattern is associated with uteroplacental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply. A pattern similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the client on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a reassuring pattern, so the IV rate should be increased to increase the mother’s blood volume. These are late decelerations, not early; therefore, interventions are necessary. 210 Which maternal condition should be considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. Fetus has known heart defect d. External monitors currently being used To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A compromised fetus should be monitored with the most accurate monitoring devices. The external monitor can be discontinued after the internal ones are applied. 211 The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a. Doppler b. Fetoscope c. Scalp electrode d. Tocodynamometer Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions. 212 A client is receiving oxytocin (Pitocin) to induce labor. The uterine contractions have become persistently hypertonic and the infusion is stopped. The health care provider has prescribed a tocolytic to stop contractions. Which medication should the nurse be prepared to administer? a. Naloxone (Narcan) b. Terbutaline (Brethine) c. Ephedrine d. Diphenhydramine (Benadryl) A tocolytic drug, such as terbutaline (0.125 to 0.25 mg IV or 0.25 mg subcutaneously), may be given to reduce uterine activity. Narcan is a narcotic antagonist. Benadryl is an antihistamine. Ephedrine is a vasopressor used to increase blood pressure. 213 Proper placement of the tocotransducer for electronic fetal monitoring is: a. inside the uterus. b. on the fetal scalp. c. over the uterine fundus. d. over the mother’s lower abdomen. The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area. 214 Which can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions Beat-to-beat variability cannot be determined by auscultation because auscultation provides only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR monitoring techniques. The fetal response to the contractions is usually noted by an increase or decrease in fetal heart rate. These can be determined by any of the FHR monitoring techniques. 215 Which is the most appropriate method of intrapartum fetal monitoring when a woman has a history of hypertension during pregnancy? a. Continuous auscultation with a fetoscope b. Continuous electronic fetal monitoring c. Intermittent assessment with a Doppler transducer d. Intermittent electronic fetal monitoring for 15 minutes each hour Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications. 216 Why is continuous electronic fetal monitoring generally used when oxytocin is administered? a. Fetal chemoreceptors are stimulated. b. The mother may become hypotensive. c. Maternal fluid volume deficit may occur. d. Uteroplacental exchange may be compromised. The uterus may contract more firmly and the resting tone may be increased with oxytocin use. This response reduces the entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk. 217 The nurse is concerned that a client’s uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? a. Reposition the tocotransducer. b. Reposition the Doppler transducer. c. Obtain an order from the health care provider for a spiral electrode. d. Obtain an order from the health care provider for an intrauterine pressure catheter. An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this would not be accurate with an obese client, even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral electrode) measures the fetal heart rate (FHR). 218 If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? a. Right upper b. Left upper c. Right lower d. Left lower If the fetus is in a right occiput anterior position, the fetal spine will be on the mother’s right side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be in the right lower quadrant. The right upper, left upper, and left lower areas are not the best locations for assessing the fetal heart rate in this case. 219 In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? a. The fetus is at 30 weeks of gestation. b. The mother has a history of fast labors. c. The mother has been given an epidural block. d. The mother has mild preeclampsia but is not in labor. The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR with an epidural is not considered an expected outcome. Preeclampsia should not cause a normal elevation of the FHR. 220 When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? a. Reposition the client. b. Apply a fetal scalp electrode. c. Record this reassuring pattern. d. Administer oxygen by nasal cannula. The periodic pattern described is early deceleration that is not associated with fetal compromise and requires no intervention. It is a reassuring pattern. Repositioning the client, applying a fetal scalp electrode, or administering oxygen would be interventions done for nonreassuring patterns. 221 When the mother’s membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a. Early decelerations b. Variable decelerations c. Nonperiodic accelerations d. Increase in baseline variability When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes. 222 In which situation would it be appropriate to obtain a fetal scalp blood sample to establish fetal well-being? a. The fetus has developed tachycardia related to maternal fever. b. The mother has vaginal bleeding, and the baseline fetal heart rate is decreasing. c. The fetal heart tracing on a preterm fetus shows decreased baseline variability. d. The fetal heart tracing shows a persistent pattern of late decelerations, with normal baseline variability. The tracing is nonreassuring, and additional assessment is needed regarding the acid-base status of the fetus. Fetal scalp blood sampling is contraindicated with vaginal bleeding, maternal fever, and a preterm fetus. 223 The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing: a. a worsening hypoxia. b. progressive acidosis. c. a reassuring response. d. parasympathetic stimulation The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic stimulation with a temporary increase in the fetal heart rate (FHR) baseline. An increase in the FHR with stimulation does not indicate hypoxia. An increase in the FHR after stimulation is reassuring and does not indicate acidosis. An increase in the FHR after stimulation is a reassuring pattern and does not indicate problems with the parasympathetic nervous system. 224 When a nonreassuring pattern of the fetal heart rate is noted and the client is lying on her left side, which nursing action is indicated? a. Lower the head of the bed. b. Place a wedge under the left hip. c. Change her position to the right side. d. Place the mother in Trendelenburg position. Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. Lowering the head of the bed would not be the first position change choice. The woman is already on her left side, so a wedge on that side would not be an appropriate choice. Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted; the Trendelenburg position might be the choice 225 Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by: a. expanding the maternal blood volume. b. maintaining a normal maternal temperature. c. preventing normal maternal hypoglycemia. d. increasing the oxygen-carrying capacity of the maternal blood. Filling the mother’s vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not add extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells. 226 Which nursing action is correct when initiating electronic fetal monitoring? a. Lubricate the tocotransducer with an ultrasound gel. b. Securely apply the tocotransducer with a strap or belt. c. Inform the client that she should remain in the semi-Fowler position. d. Determine the position of the fetus before attaching the electrode to the maternal abdomen. The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately. The tocotransducer does not need gel to operate appropriately. The client should be encouraged to move around during labor. The tocotransducer should be placed at the fundal area of the uterus. 227 Which statement correctly describes the nurse’s responsibility related to electronic monitoring? a. Report abnormal findings to the physician before initiating corrective actions. b. Teach the woman and her support person about the monitoring equipment and discuss any of their questions. c. Document the frequency, duration, and intensity of contractions measured by the external device. d. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place. Teaching is an essential part of the nurse’s role. Corrective actions should be initiated first to correct abnormal findings as quickly as possible. Electronic monitoring will record the contractions and FHR response. The support person should still be encouraged to assist with the comfort measures. 228 Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation? a. Inhibition of epinephrine b. Inhibition of norepinephrine c. Stimulation of the vagus nerve d. Sympathetic stimulation Sympathetic nerve innervation would result in an increase in fetal heart rate. The release of epinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. The release of norepinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate. Stimulation of the vagus nerve would indicate parasympathetic innervation and result in a decreased heart rate. 229 Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? a. External fetal monitoring (EFM) b. Internal fetal monitoring c. Intrauterine pressure catheter (IUPC) d. Maternal comments based on perception IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength. EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and contraction pattern. It only estimates uterine contraction strength. Maternal comments related to pain may not be related to uterine contraction strength and thus are influenced by the client’s own pain perception. 230 The physician has ordered an amnioinfusion for the laboring client. What data supports the use of this therapeutic procedure? a. Presenting part not engaged b. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) c. Breech position of fetus d. Twin gestation Amnioinfusion is a procedure used during labor when cord compression or the detection of gross meconium staining is found in the amniotic fluid. A saline solution is used as an irrigation method through the IUPC (intrauterine pressure catheter). 231 Which of the following is the priority intervention for a supine client whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? a. Increase IV infusion. b. Elevate lower extremities. c. Reposition to left side-lying position. d. Administer oxygen per face mask at 4 to 6 L/min. Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the client is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the client is in a supine position. 232 Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should: a. maintain the normal assessment routine. b. administer O2 at 8 to 10 L/min by face mask. c. increase the IV flow rate from 125 to 150 mL/hr. d. assess the maternal blood pressure for a systolic pressure below 100 mm Hg. Decelerations that mirror the contraction are early decelerations caused by fetal head compression. Early decelerations are not associated with fetal compromise and require no intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are not necessary in early decelerations. 233 To clarify the fetal condition when baseline variability is absent, the nurse should first: a. monitor fetal oxygen saturation using fetal pulse oximetry. b. notify the physician so that a fetal scalp blood sample can be obtained. c. apply pressure to the fetal scalp with a glove finger using a circular motion. d. increase the rate of nonadditive IV fluid to expand the mother’s blood volume. Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in response to the massage suggests that the fetus is in normal oxygen and acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer available in the United States. Obtaining a fetal scalp blood sample is invasive and the results are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the fetal condition. 234 Which client is a candidate for internal monitoring with an intrauterine pressure catheter? a. Obese client whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds b. Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds c. Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds d. Gravida 2, para 1, in latent phase whose contractions are irregular and mild A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60 seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of uterine activity. Irregular and mild contractions are common in the latent phase. 235 Which client has the priority need for fetal monitoring? a. Primigravida at 38 weeks with spontaneous ROM b. Multigravida at 40 weeks with history of 10-hour labors c. Multigravida admitted for repeat elective cesarean section d. Primigravida at 39 weeks with meconium-stained amniotic fluid Meconium-stained amniotic fluid indicates a potential risk factor during labor. Primigravida at 38 weeks with spontaneous ROM, multigravida with a history of 10-hour labors, and multigravida admitted for repeat elective cesarean section do not have potential maternal or fetal risk factors. 236 Which of the following is the priority intervention for the client in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? a. Administer O2 at 8 to 10 L/min. b. Decrease the IV rate to 100 mL/hr. c. Reposition the ultrasound transducer. d. Perform a vaginal exam to assess for cord prolapse. A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the client’s blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation. 237 When a pattern of variable decelerations occur, the nurse should: a. administer O2 at 8 to 10 L/min. b. place a wedge under the right hip. c. increase the IV fluids to 150 mL/hr. d. position client in a knee-chest position. Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The client should be repositioned when the FHR pattern is associated with cord compression. The knee-chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression. 238 The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability. What is the priority action based on these findings? a. Document the findings. b. Contact the health care provider. c. Increase the rate of the existing IV to 200 mL/hr as per the standing prescription. d. Place oxygen via a rebreather mask at 10 L/min as per the standing prescription. The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors. 239 The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient’s contractions. How will the nurse document these findings? a. Late decelerations b. Early decelerations c. Variable decelerations d. Proximal decelerations Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction’s peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal decelerations is not a recognized term 240 A patient at 41 weeks’ gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse’s priority action? a. Stop the infusion of Pitocin. b. Reposition the patient from her right to her left side. c. Perform a vaginal exam to assess for a prolapsed cord. d. Prepare the patient for an emergency cesarean section. There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. The presence of two or more nonreassuring fetal heart rate patterns increases the level of concern. 241 The nurse admits a laboring patient at term. On review of the prenatal record, the patient’s pregnancy has been unremarkable and she is considered low risk. In planning the patient’s care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? a. Every 10 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage. 242 Childbirth preparation can be considered successful if the outcome is described as which of the following? a. Labor was pain-free. b. The birth experiences of friends and families were ignored. c. Only nonpharmacologic methods for pain control were used. d. The client rehearsed labor and practiced skills to master pain. Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain- free labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realistic information about labor pain. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone. 243 A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated with opiate-dependent patients? a. Nalbuphine (Nubain) b. Hydroxyzine (Vistaril) c. Promethazine (Phenergan) d. Diphenhydramine (Benadryl) Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics. 244 A client is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or do procedures? a. After the contraction is over b. When it is all right with the coach c. During increment of next contraction d. After administration of analgesic-anesthetic Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in the woman, preventing her from answering questions correctly. 245 Childbirth pain is different from other types of pain in that it is: a. less intense. b. associated with a physiologic process. c. more responsive to pharmacologic management. d. designed to make one withdraw from the stimulus Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during labor may affect the course and length of labor. The pain with childbirth is a normal process; it is not caused by the type of injury as when withdrawal from the stimulus occurs. 246 Excessive anxiety during labor heightens the client’s sensitivity to pain by increasing: a. muscle tension. b. the pain threshold. c. blood flow to the uterus. d. rest time between contractions. Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman’s brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets between contractions. 247 Which fetal position may cause the laboring client more back discomfort? a. Left occiput anterior b. Left occiput posterior c. Right occiput anterior d. Right occiput transverse In the left occiput posterior position, each contraction pushes the fetal head against the mother’s sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position. 248 A major advantage of nonpharmacologic pain management is that: a. a more rapid labor is likely. b. more complete pain relief is possible. c. the woman remains fully alert at all times. d. there are no side effects or risks to the fetus. Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at a quicker pace. The woman’s alertness is not altered by medication, but the increase in pain will decrease alertness. 249 The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a. Latent phase b. Active phase c. Second stage d. Transition phase The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time 250 The primary side effect of maternal narcotic analgesia in the newborn is: a. tachypnea. b. bradycardia. c. acrocyanosis. d. respiratory depression. An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. 251 A client received 25 mg of meperidine (Demerol) intravenously 1 hour before birth. Which drug should the nurse have readily available? a. Naloxone (Narcan) b. Butorphanol (Stadol) c. Nalbuphine (Nubain) d. Promethazine (Phenergan) Naloxone (Narcan) reverses narcotic-induced respiratory depression, which may occur with the administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics given to women in labor. 252 The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n): a. local. b. epidural. c. pudendal. d. spinal block. A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs. 253 A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session? a. It usually results in a more rapid labor. b. It has no effect on the outcome of labor. c. It is considered to be a normal occurrence. d. It may result in decreased placental perfusion. When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed. 254 Which client will most likely have increased anxiety and tension during labor? a. Gravida 2 who refused any medication b. Gravida 2 who delivered a stillborn baby last year c. Gravida 1 who did not attend prepared childbirth classes d. Gravida 3 who has two children younger than 3 years If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect. 255 Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? a. Narcotics b. Spinal block c. Epidural anesthesia d. Breathing and relaxation techniques Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn. 256 A laboring client who imagines her body opening to let the baby out is using a mental technique called: a. imagery. b. effleurage. c. distraction. d. dissociation. Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working. 257 When giving a narcotic to a laboring client, which statement explains why the nurse should inject the medication at the beginning of a contraction? a. The medication will be rapidly circulated. b. Less medication will be transferred to the fetus. c. The maternal vital signs will not be adversely affected. d. Full benefit of the medication is received during that contraction. Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus. 258 The method of anesthesia in labor that is considered the safest for the fetus is: a. epidural block. b. pudendal block. c. local infiltration. d. spinal (subarachnoid) block. Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension. 259 To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should: a. give the woman oxygen. b. turn the woman to the right side. c. decrease the intravenous infusion rate. d. place a wedge under the woman’s right hip Tilting the woman’s pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. However, placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension. 260 Which clinical effect can occur in the presence of increased maternal pain perception during labor? a. Increase in uterine contractions in response to catecholamine secretion b. Decrease in blood pressure in response to alpha receptors c. Decreased perfusion to the placenta in response to catecholamine secretion d. Increased uterine blood flow, causing increase in maternal blood pressure Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure. 261 Which of the following factors would affect pain perception or tolerance for the laboring client? a. Right occiput posterior fetal position during labor b. Bishop score of 10 prior to the induction of labor c. Gynecoid pelvis d. Absence of Ferguson’s reflex A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Ferguson’s reflex occurs when a contraction is stimulated as a result of vaginal stimulation. 262 A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority intervention should be done by the nurse to help evaluate clinical response to treatment? a. Obtain a pain scale response from the client based on a 0 to 10 scale. b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. c. Document intake and output on the electronic health record (EHR). d. Increase the flow rate of prescribed parenteral fluid to maintain hydration. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this client’s situation. Increasing the flow rate of parenteral fluids requires a physician’s order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess. 263 The process of labor places significant metabolic demands on the obstetric client. Which physiologic findings would be expected? a. Decreased maternal blood pressure as a result of stimulation of alpha receptors b. Uterine vasoconstriction as a result of stimulation of beta receptors c. Increased maternal demand for oxygen d. Increased blood flow to placenta because of catecholamine release With regard to labor, one would expect to see an increase in maternal blood pressure because of stimulation of alpha receptors. Uterine vasoconstriction would occur in response to stimulation of alpha receptors. One would expect to see a decrease in blood flow to the placenta. The maternal metabolic rate is increased during labor, along with an increase in maternal demand for oxygen. 264 A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration? a. Oxytocin (Pitocin) b. Naloxone (Narcan) c. Bromocriptine (Parlodel) d. Oxygen Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression. 265 Which statement is true with regard to the type of pain associated with childbirth experience? a. Pain is constant throughout the labor experience b. Labor pain during childbirth is considered to be an abnormal response. c. Pain associated with childbirth is self-limiting. d. Pain associated with childbirth does not allow for adequate preparation. The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a normal response during childbirth. Pregnant woman can prepare for the expected pain of childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor. 266 A pregnant woman is in the second stage of labor and is actively pushing. What type of pain would she be most likely to experience? a. Deep, poorly localized pain b. Visceral pain c. Slow, dull, aching pain d. Somatic pain Somatic pain is quick, sharp, and precisely localized and is seen during the second stage of labor. Deep, poorly localized pain is associated with visceral pain, which predominates during the first stage of labor. Visceral pain is slow, deep, dull, aching, and poorly localized. Slow, dull, aching pain is characteristic of visceral pain. 267 Which of the following clients could be a candidate for a vaginal birth after cesarean section (VBAC)? a. A 32-year-old gravida 2, para 1, who had a primary cesarean section for fetal distress b. A 23-year-old gravida 3, para 2, who had two cesarean sections with classic incisions c. An 18-year-old gravida 3, para 2, who had cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively d. A 25-year-old gravida 1, para 0, who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth disproportion (CPD) and macrosomia. A client who has had a prior classic incision into the uterus is not a candidate for this type of procedure. Based on the presented history of a cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively, this client is at risk for uterine rupture and for delivering another macrosomic infant because she has already had two cesarean sections for the same indications. A client who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth is not a candidate for a VBAC because she does not meet the clinical criteria. 268 A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes. The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment? a. Use contact anesthesia for an epidural and prepare the client per protocol. b. Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop. c. Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. d. Call the physician for admitting orders. By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the client’s needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the client’s concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician. 269 A labor client has brought in with her a picture of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of: a. focal point. b. distraction. c. effleurage. d. relaxation. The use of a focal point (image and/or point reference in the labor room) is an example of nonpharmacologic pain control during labor. The image of the client’s children is not serving as a method of distraction. Effleurage is the use of massage techniques to minimize pain perception. The image of the client’s children is not serving as a method of relaxation. 270 A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention? a. Perform a vaginal exam to denote progress. b. Reposition the client to a side lying position. c. Instruct the client to breathe into her cupped hands. d. Notify the physician about current findings. This client is exhibiting signs of hyperventilation associated with a rapid breathing pattern, which can occur during the labor process. The nurse should instruct the client to breathe into her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process. A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in labor progress. Repositioning the client may be an option but is not the priority intervention at this time. Notifying the physician is not appropriate at this time because the RN should attend to actions that are readily available to her based on her scope of practice and standard of care. The physician may have to be notified once the intervention has been performed. 271 Your laboring client has asked that you help her to use a cutaneous stimulation strategy for pain management, you would then: a. assist her into the shower. b. apply a heat pack to lower back. c. help her to create a relaxing mental scene. d. encourage cleansing breaths and slow-paced breathing Cutaneous stimulation includes self-massage, massage by others, counterpressure, touch, thermal stimulation, and acupressure. A shower, tub, or whirlpool are forms of hydrotherapy; creating a relaxed mental scene is mental stimulation. The use of cleansing breaths and patterned breathing is part of breathing techniques for labor. 272 To relieve a mild postdural puncture headache, the nurse should encourage the intake of: a. milk. b. orange juice. c. tea or coffee. d. beef or chicken bouillon Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine. 273 The priority intervention for a client with epidural anesthesia whose blood pressure is 80/50 mm Hg is: a. reposition to supine position. b. administer ephedrine, 5 mg IV push. c. maintain IV infusion rate at 150 mL/hr. d. Notify anesthesia about maternal hypotension. A significant blood pressure decrease is a drop to 100 mm Hg or lower systolic. If hypotension is significant, ephedrine is ordered to increase the blood pressure to normal values. The supine position will further decrease maternal blood pressure by compressing the major vessels. Maintaining the IV infusion rate will not return blood pressure to normal values as quickly as needed; immediate action needs to be taken, and notifying anesthesia would be time-consuming. 274 Which client will be most receptive to teaching about nonpharmacologic pain control methods? a. Gravida 1, para 0, in transition b. Gravida 2, para 1, admitted at 8 cm c. Gravida 1, para 0, dilated 2 cm, 80% effaced d. Gravida 3, para 2, complaining of intense perineal pressure The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Clients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a client whose birth is imminent. 275 The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse’s priority action for this patient? a. Ask the patient’s labor coach if this is a usual expression of pain for her. b. Refer to the patient’s chart to determine any orders for pain medication. c. Tell the patient that she is disturbing the other laboring patients on the unit. d. Encourage the patient to try to suppress her noisiness during contractions. Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a woman’s personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a woman’s individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others. 276 A multipara’s labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request? a. Maternal pulse b. Maternal temperature c. Maternal blood pressure d. Maternal blood glucose level A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several studies have shown benefits of water therapy during labor, including immersion in a tub or whirlpool (jet hydrotherapy, or Jacuzzi). The major concern about immersion therapy has been newborn and postpartum maternal infections caused by microorganisms in the water. Infections can be caused by the woman’s own ascending vaginal bacteria or by preexisting organisms in an improperly cleaned tub. However, several studies have not found a significant association between newborn or postpartum maternal infections and the use of immersion hydrotherapy with proper cleaning. 277 A patient in active labor requests an epidural for pain management. What is the nurse’s priority action for this patient? a. Assess the fetal heart rate pattern over the next 30 minutes. b. Take the patient’s blood pressure every 5 minutes for 15 minutes. c. Determine the patient’s contraction pattern for the next 30 minutes. d. Initiate an IV infusion of lactated Ringer’s solution at 2000 mL/hr over 30 minutes. Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringer’s or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation. 278 Meperidine (Demerol), 50 mg IV, has been ordered for a laboring patient. The patient is contracting every 3 minutes, with a duration of 45 to 60 seconds. What is the nurse’s best plan for administering the IV medication? a. Inject the medication between two contractions. b. Inject the medication during and after a single contraction. c. Inject the medication at the start of the next two contractions. d. Inject the medication throughout the duration of a single contraction. The suggested administration of IV Demerol is 25 mg/min and therefore will need to be administered over the course of two contractions. Opioid analgesics are given in small frequent doses by the IV route during labor to provide a rapid onset of analgesia and predictable duration of action. The woman will benefit from rapid pain control, with less likelihood of neonatal respiratory depression. Starting the injection at the beginning of the contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. When placental blood flow resumes, more of the drug is in maternal tissues. 279 You are preparing a client for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.) a. Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement. b. Have ephedrine available at bedside during catheter placement. c. Monitor blood pressure of client frequently during catheter insertion and for the first 15 minutes of epidural administration. d. Insert a Foley catheter prior to epidural catheter placement. e. Monitor the client for hypertension in response to epidural insertion. A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is 280 The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) a. Encourage the client to drink fluids. b. Place the client in a Trendelenburg position. c. Administer a normal saline bolus as prescribed. d. Administer oxygen at 8 to 10 L/min per face mask. e. Administer IV ephedrine in 5- to 10-mg increments as prescribed. If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client. 281 The nurse is preparing a client for a cesarean section scheduled to be done under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents? (Select all that apply.) a. Citric acid (Bicitra) b. Ranitidine (Zantac) c. Hydroxyzine (Vistaril) d. Glycopyrrolate (Robinul) e. Promethazine (Phenergan) To prevent aspiration of gastric contents during general anesthesia administration of medications to raise the gastric pH and make secretions less acidic, such as citric acid (Bicitra) and ranitidine (Zantac) may be prescribed. In addition, medications to reduce secretions, such as glycopyrrolate (Robinul) may be prescribed. Hydroxyzine (Vistaril) and promethazine (Phenergan) are used to prevent and relieve nausea often associated with opioids. 282 The nurse knows that a urinary catheter is added to the instrument table if a forceps-assisted birth is anticipated. The correct rationale for this intervention is that: a. a sterile urine specimen is needed preoperatively. b. an empty bladder provides more room in the pelvis. c. spontaneous release of urine might contaminate the sterile field. d. a Foley catheter prevents the membranes from spontaneously rupturing. Catheterization provides room for the application of the forceps blades and limits bladder trauma. A clean-catch urinalysis is usually sufficient for preoperative treatment. Urine is sterile. The membranes must be ruptured and the cervix completely dilated for a forceps-assisted birth. 283 After a forceps-assisted birth, the client is observed to have continuous bright red lochia but a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma? a. Lack of an episiotomy b. Mild, intermittent perineal pain c. Lack of pain in the perineal area d. Edema and discoloration of the labia and perineum The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe. 284 The nurse is positioning the Foley catheter prior to a cesarean birth. Which position should the nurse use to place the catheter drainage tubing and catheter bag? a. Place near the head of the table. b. Position on top of the patient’s leg. c. Place at the foot and clamp during the cesarean section. d. Position at the foot of the surgeon under the sterile drapes. The drain tube of the catheter should be positioned under the client’s to promote drainage and to keep the catheter away from the operative area. Urinary output must be continuously monitored. An early sign of hypovolemia is decreasing urinary output. The anesthesia clinician must monitor urine output during the surgery so it should not be clamped. The surgeon might step on the drainage bag if the catheter were below the drapes, and no one could monitor the urine output. 285 Which condition is a contraindication for an amniotomy? a. –2 station b. Breech presentation c. Dilation less than 3 cm d. Right occiput posterior position A prolapsed cord can occur if the membranes artificially rupture when the presenting part is not engaged. The presenting part should be cephalic. The dilation must be enough to determine labor. Right occiput posterior is a cephalic presentation appropriate for an amniotomy. 286 Which client status is an acceptable indication for serial oxytocin induction of labor? a. Multiple fetuses b. Polyhydramnios c. History of long labors d. Past 42 weeks of gestation Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. Multiple fetuses overdistend the uterus, making induction of labor high risk. Polyhydramnios overdistends the uterus, making induction of labor high risk. A history of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances. 287 The nurse is explaining the technique of internal version to a group of nursing students. Which describes the technique of internal version? a. Manipulation of the fetus from a breech to a cephalic presentation before labor begins b. Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean birth c. Manipulation of the second twin from an oblique lie to a transverse lie before labor begins d. Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated. For internal version to occur, the cervix needs to be dilated. Internal version is done to turn the second twin after the first twin is born. 288 The greatest risk to the newborn after an elective cesarean birth is: a. tachypnea because of maternal anesthesia. b. tachycardia because of maternal narcotics. c. trauma because of manipulation during birth. d. prematurity because of miscalculation of gestation. Regardless of the many criteria used to determine gestational age, inadvertent preterm birth still occurs. Maternal anesthesia may cause respiratory distress. Maternal narcotics may cause respiratory distress. There is less trauma with a cesarean birth 289 Which client is most at risk for a uterine rupture? a. A gravida 4 who had a classic cesarean incision b. A gravida 5 who had two vaginal births and one cesarean birth c. A gravida 3 who has had two low-segment transverse cesarean births d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The client who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Low- segment incisions do not raise the risk of uterine ruptures. 290 Before the health care provider performs an external version, the nurse should expect an order for a: a. Foley catheter. b. tocolytic drug. c. local anesthetic. d. contraction stress test (CST). A tocolytic drug will relax the uterus before and during version, making manipulation easier. The bladder should be emptied, but catheterization is not necessary. A local anesthetic is not used with external version. CST is used to determine the fetal response to stress. 291 A maternal indication for the use of vacuum extraction is: a. a wide pelvic outlet. b. maternal exhaustion. c. a history of rapid deliveries. d. failure to progress past 0 station. The client who is exhausted will be unable to assist with the expulsion of the fetus. With a wide pelvic outlet, vacuum extraction would not be necessary. With a rapid birth, vacuum extraction would not be necessary. A station of 0 is too high for a vacuum extraction. 292 The priority nursing intervention following an amniotomy is to: a. change the client’s gown. b. assess the fetal heart rate. c. assess the color of the amniotic fluid. d. estimate the amount of amniotic fluid. The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Changing the gown is important for client comfort but is not the top priority. Assessing the amount of amniotic fluid is important but is not the top priority. Estimating the amount of amniotic fluid is not a top priority for this client. 293 For which client should the oxytocin (Pitocin) infusion be discontinued immediately? a. A client in transition with contractions every 2 minutes lasting 90 seconds each b. A client in early labor with contractions every 5 minutes lasting 40 seconds each c. A client in active labor with contractions every 3 minutes lasting 60 seconds each d. A client in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each This client’s contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this client’s contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this client’s contractions. There is an appropriate resting period between this client’s contractions for her stage of labor. 294 The priority nursing care associated with an oxytocin infusion is: a. measuring urinary output. b. evaluating cervical dilation. c. monitoring uterine response. d. increasing infusion rate every 30 minutes. Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse’s priority intervention is monitoring uterine response. Monitoring urinary output is important with Pitocin but not the top priority. Monitoring labor progression is important but not the top priority. The infusion rate may be increased but only after proper assessment that it is appropriate. 295 Which event indicates a complication of an external version? a. Maternal pulse rate of 100 bpm b. Fetus returning to the original position c. Increased maternal anxiety after the version d. Fetal bradycardia persisting 10 minutes after the version Fetal bradycardia after a version may indicate that the umbilical cord has become compressed, and the fetus is having hypoxia. There are few risks to the client during an external version. The fetus may return to the original position, but this is not a complication of the version. Anxiety may occur before the version but should decrease after the procedure is completed. 296 Immediately following the forceps-assisted birth of an infant, which action should the nurse implement? a. Assess the infant for signs of trauma. b. Apply a cold pack to the infant’s scalp. c. Give the infant prophylactic antibiotics. d. Measure the circumference of the infant’s head. Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This would put the infant at risk for cold stress and would be contraindicated. Prophylactic antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is part of the initial nursing assessment. 297 Nursing care before a cesarean birth should include: a. full perineal shave preparation. b. administering a clear oral antacid. c. injection of narcotic preoperative medications. d. straight catheterization to empty the bladder. General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes gastric acid and reduces potential lung injury if the client vomits and aspirates gastric contents during anesthesia. Perineal preparation is not necessary for a cesarean section. Some agencies will do an abdominal prep just before the surgery. A narcotic at this point would put the fetus at high risk for respiratory distress. The catheterization should be indwelling to keep the bladder small during the surgery. 298 A gravida 2, para 1 client is admitted to the labor and birth unit in labor. She states that she had a cesarean birth with her first pregnancy. The most critical information the nurse must obtain at this point is: a. the onset of contractions. b. her estimated date of birth. c. when the client ate last and what she consumed. d. the type of uterine incision with the first pregnancy A vertical incision creates a greater risk of uterine rupture in a subsequent labor than a transverse incision. The onset of labor is not the most important information that is needed at this point. This is important information to prepare for a fetus that may not be term. However, it is not the most critical question. If a cesarean birth is necessary this information is needed but not as critical as the type of previous incision. 299 Which is an appropriate response to a client’s comment that she is worried about having a cesarean birth? a. “Don’t worry. Everything will be okay.” b. “Clients commonly worry about surgery.” c. “What are your feelings about having a cesarean birth? d. “I know you’re worried, but this is a routine procedure.” Allowing the client to express her feelings is the most appropriate nursing response. The nurse should never provide the client with false reassurance or disregard her feelings. Saying to not worry is belittling the client’s concerns and does not allow her to express her concerns. Saying clients commonly worry about surgery is closed-ended and belittling to the client’s feelings. Acknowledging the worry but stating that the procedure is just routine is stating that the client’s feelings are not important. 300 While assisting with a vacuum extraction birth, which should the nurse immediately report to the physician? a. Maternal pulse rate of 100 bpm b. Maternal blood pressure of 120/70 mm Hg c. Persistent fetal bradycardia below 100 bpm d. Decreased intensity of uterine contractions Fetal bradycardia may indicate fetal distress and may require immediate intervention. Maternal pulse rate may increase due to the pushing process. Blood pressure of 120/70 mm Hg is within expected norms for this stage of labor. Decreased intensity of uterine contractions indicates the birth is imminent at this point. 301 To monitor for potential hemorrhage in the client who has just had a cesarean birth, which action should the recovery room nurse implement? a. Monitor her urinary output. b. Maintain an intravenous infusion at 1 mL/hr. c. Assess the abdominal dressings for drainage. d. Assess the uterus for firmness every 15 minutes. Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room. 302 The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of a client. With which client should the nurse question the use of vaginal prostaglandin as a cervical ripening agent? a. The client who has a Bishop’s score of 5 b. The client who is at 42 weeks of gestation c. The client who had a previous low transverse cesarean birth d. The client who had previous surgery in the upper uterus Prostaglandins are contraindicated in clients who have had a previous surgery in the upper uterus, such as a previous classic cesarean incision or extensive surgery for uterine fibroids. A side effect of prostaglandin administration is hyperstimulation of the uterus. A Bishop’s score of 5, 42 weeks of gestation, or a previous low transverse cesarean birth are not contraindications for cervical ripening. 303 A vaginal exam for a laboring multipara client who is 42 weeks’ gestation reveals the following information: 4 cm, minimal effacement, -2 station. Which clinical factors would affect the clinical management decision not to rupture membranes with an AmniHook? a. Vaginal dilation b. Client is a multipara c. Presenting part is at –2 station d. Gestational age The fact that the presenting part is not engaged causes concern because there is increased risk of a prolapsed cord on artificial rupture of membranes (AROM). Vaginal dilation is adequate for attempt to rupture membranes. The fact that a client is a multipara is not a significant reason to affect clinical decision making with regard to AROM. Postdates of pregnancy may warrant a more aggressive approach to speed the labor and birth process. 304 A client who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority? a. Increase rate of Pitocin infusion to help spread out contraction pattern. b. Place oxygen on client at 8 to 10 L/min via face mask and turn client to left side. c. Stop Pitocin infusion. d. Call physician to obtain an order for initiation of magnesium sulfa The client is exhibiting uterine tachysystole (uterine tetany). Priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be called for additional orders. 305 Which clinical finding indicates the use of vacuum extraction as a birth method? a. Mentum presentation of the fetus b. Presence of caput succedaneum c. Maternal exhaustion as a result of ineffective pushing during second stage of labor d. Physician preference Vacuum extraction is used in place of forceps as an assistive method to help with the birth of the fetus. It is not used in nonvertex presentations. Mentum presentation is where the chin is the presenting part. Vacuum extraction should not be used in the presence of caput succedaneum (swelling) or in the presence of excessive molding. 306 Which of the following factors would lead to an increased risk for a prolapsed cord to occur during an amniotomy? a. Presenting part engaged b. Postdated pregnancy c. Preterm pregnancy d. Term pregnancy Prolapsed cord is more likely to occur when the presenting part is not engaged and the pregnancy is preterm because the fetus would be smaller and there would potentially be more amniotic fluid. If the presenting part is engaged and the pregnancy is at term or postdated, it is less likely that a prolapsed cord would occur. 307 A client is being sent into the labor and birth unit for a serial induction of labor. The Bishop’s score is 7. What would the nurse anticipate as the sequence of treatment planned for this client? a. Administration of laminaria with EFM followed by amniotomy and oxytocin (Pitocin) infusion in a 12-hour period b. Amniotomy on the first day in conjunction with EFM followed by oxytocin (Pitocin) infusion on the following clinical day c. Administration of oxytocin (Pitocin) on the first day followed by amniotomy on the second clinical day d. Administration of laminaria with EFM on the first day followed by oxytocin (Pitocin) infusion on the second day and evaluation of progress; on the third day, continued oxytocin (Pitocin) infusion with amniotomy A serial induction looks at a progressive treatment plan that is based on the best outcome, that of a successful birth. Because the Bishop’s score is 7, this indicates that certain conditions are not favorable for an induction. Therefore, the use of mechanical methods for cervical ripening maybe warranted. A serial induction is typically done over a 3-day period in which cervical ripening is followed by 2 days of Pitocin infusion, and on the last day an amniotomy is performed in conjunction with the infusion. 308 On vaginal exam, the client’s cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishop’s score for this client is: a. 6. b. 9. c. 10. d. 12. On the Bishop’s scoring system, an anterior cervix = 2 points, soft cervix = 2 points, 70% effaced = 2 points, 2 cm dilated = 1 point, and 0 station = 2 points, for a total score of 9. 309 Select the situation that describes the safest administration of oxytocin induction and cervical ripening agents. a. Concurrent use of oxytocin and dinoprostone (Cervidil) b. Misoprostol (Cytotec) 25 mcg, followed in 4 hours by oxytocin induction in vaginal birth after cesarean section (VBAC) client c. Dinoprostone (Cervidil) 10 mg in place for 12 hours followed by oxytocin induction in 1 hour d. Maximum dose of dinoprostone (Prepidil) 2 mg/24 hr followed in 4 hours by oxytocin induction Dinoprostone (Cervidil) in a 10-mg, time-release insert may be left in place for up to 12 hours and oxytocin induction can be safely started 1 hour after insert is removed. Oxytocin and cervical ripening agents cannot be administered at the same time. Misoprostol (Cytotec) is contraindicated in a women with previous cesarean. The maximum dose of dinoprostone (Prepidil) 1.5 mg/24 hr. 310 When a laboring client receiving 12 mU of pitocin for induction develops a contraction pattern of every 2 minutes lasting 80 seconds and recurring late decelerations, the nurse should immediately: a. stop oxytocin infusion. b. administer O2 at 8 TO 10 L/min. c. reposition client to left side-lying position. d. increase the rate of the primary nonadditive infusion. Uterine hyperstimulation can reduce placental blood flow and decrease fetal oxygenation. Late decelerations are caused by uteroplacental insufficiency. Stopping the oxytocin infusion will reduce uterine activity and increase fetal oxygenation. Administering O2, repositioning the client, and increasing the rate of the primary nonadditive infusion will not be effective until hyperstimulation is resolved. 311 Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth? a. Presence of newborn reflexes b. Symmetry of facial movements c. Caput and molding of the head d. Anterior and posterior fontanels Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and molding, and changes in the anterior and posterior fontanels are not risks associated with trauma to the infant’s face. 312 Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth? a. Anterior fontanel b. Coronal suture lines c. Posterior fontanel d. Biparietal diameter The vacuum extractor is applied on the occipital bone and may create scalp edema at the application site. The posterior fontanel connects the occipital bone to the parietal bones. The anterior fontanel, coronal suture lines, and parietal bones are not part of the application area for a vacuum extractor. 313 In which client situation could an amniotomy be safely performed? a. G1 P0, 38 weeks’ gestation, 20% effaced, closed cervix b. G2 P1, 40 weeks’ gestation, with fetus in a breech presentation c. G2 P0, 39 weeks’ gestation, 70% effaced, cervix dilated 2 cm d. G3 P2, 41 weeks’ gestation, early labor complicated with hydramnios The cervix must be partially open to allow the membranes to be ruptured. An amniotomy cannot be performed when the cervix is closed. Breech presentation would be delivered by cesarean section and membranes would be ruptured at birth. Rupturing the membranes in a client with hydramnios can result in abruptio placentae. 314 When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurse’s best response would be to: a. stop the drip immediately. b. decrease the dose to 14 mU/min. c. reassess the patient at 5 minute intervals. d. reposition the patient to the left side-lying position. In the absence of any adverse fetal response, hypertonic stimulation can be managed by reducing the infusion rate by 1 to 2 mU/min until uterine hyperstimulation is resolved. Stopping the drip immediately is not necessary unless hyperstimulation continues and adverse fetal responses occur. Reassessing and repositioning are of no benefit in this situation. 315 Which breech presentation should the nurse recognize as being favorable for an external cephalic version? a. 36-week gestation with low-lying placenta b. 38-week gestation with one previous cesarean c. 37-week gestation with fetal weight of 7 pounds d. 40-week gestation with several uterine fibroids An external cephalic version (changing the fetal presentation from breech to cephalic) is more successful when the pregnancy is at least 37 weeks and there is still adequate room and fluid to manipulate the fetus but prior to term or onset of labor. A low-lying placenta, previous cesarean birth, and uterine fibroids are contraindications for version. 316 Following an external cephalic version, which assessment finding indicates a complication? a. Onset of irregular contractions b. Maternal blood pressure of 110/70 mm Hg c. Deceleration of FHR to 88 bpm d. Maternal pulse rate of 100 bpm A serious risk of external cephalic version is that the fetus may become entangled in the umbilical cord, compressing its vessels and resulting in hypoxia. The onset of irregular contractions, maternal blood pressure of 110/70 mm Hg, and maternal pulse rate of 100 bpm are normal findings. 317 In which of these situations should the nurse anticipate the use of forceps or vacuum extraction? a. Complete dilation for 2 hours at +2 station b. Complete dilation for 1 hour, transverse arrest at station +1 c. Complete dilation for 3 hours, fetus at +3 station, onset of late deceleration d. Complete dilation for 1 hour, fetal descent from 0 station to + 1 in 1 hour Forceps or vacuum extraction is considered if the second stage should be shortened for the well- being of the woman or fetus. Onset of late decelerations is an indication for an operative birth. With the fetus at +3 station, an outlet operative birth can be performed. Complete dilation for 2 hours at +2 station, complete dilation for 1 hour with a transverse arrest at station +1, and complete dilation for 1 hour with fetal descent from 0 station to +1 in 1 hour are situations in which client pushing and position changes would be used before operative intervention is indicated 318 Which assessment finding is indicative of a major complication 1 hour following a forceps birth? a. Uterine fundus displaced at U + 1 b. Complaints of vaginal and uterine pain c. Peripads showing moderate lochia rubra d. Increase in pulse rate from 90 to 110 bpm Trauma to the vaginal area from a forceps birth may result in significant blood loss from hematomas or lacerations. Tachycardia is an early sign of compensation for excessive blood loss. A displaced uterine fundus is mostly likely indicative of a full bladder. Vaginal pain may be present even when the vaginal mucosa is intact. Moderate lochia rubra is a common finding early in the postpartum period. 319 A pregnant woman develops hypertension. The nurse monitors the client’s blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with what complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension. 320 The pregnant client is admitted to the labor and birth unit for induction of labor. Which finding would allow the induction to continue as planned? a. Abruptio placentae b. Cephalopelvic disproportion c. Ripening of the cervix d. Umbilical cord prolapse Procedures to ripen (soften) the cervix and make it more likely to dilate with the forces of labor are a common adjunct to induction. Most are done the day before the scheduled induction. Contraindications associated with induction may include cephalopelvic disproportion and umbilical cord prolapse. A cesarean section is indicated for abruptio placentae. 321 The pregnant client expresses a desire to schedule birth during the baby’s father’s furlough from the Army. The nurse explains that prior to induction of labor, it is essential to determine which condition? a. Dilated cervix b. Fetal lung maturity c. Rupture of membranes d. Uterine hypertonia Reassurance of fetal lung maturity is essential before elective procedures such as induction or cesarean. The cervix must be favorable for dilation but need not be dilated prior to induction. Prior rupture of membranes is not necessary for induction. Uterine hypertonia is a risk factor associated with induction of labor. 322 The nurse monitors the client in labor for signs and symptoms of water intoxication. Which finding indicates that this may be occurring? a. Hypotension b. Rales and wheezes c. Slow shallow breathing d. Tachycardia Signs and symptoms of water intoxication include headache, blurred vision, behavioral changes, increased blood pressure and respirations, decreased pulse rate, rales, wheezing, and coughing. 323 After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. What would increase the nurse’s concern about this risk? a. Hypovolemia b. Iron deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site. 324 The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 99° F [37.2° C]. What is the priority nursing action for this patient? a. Fetal acoustic stimulation b. Assess temperature every 2 hours c. Change absorption pads under her hips every 2 hours d. Review white blood cell count (WBC) drawn at admission The woman’s temperature should be assessed at least every 2 to 4 hours after the membranes rupture. Elevations above 38° C (100.4° F) should be reported. A rising FHR and fetal tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high end of the acceptable range and the maternal temperature is slightly above normal. These parameters warrant watching closely with more frequent vital signs. The WBC is often falsely elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160 bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted. Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be changed as needed. 325 The labor nurse is providing care for a patient admitted for induction of labor at 38 weeks’ gestation. The patient’s Bishop score is 5, and an infusion of oxytocin (Pitocin) is initiated with orders that read as follows: mix 30 units of Pitocin in 500 mL of NS, increase the rate of infusion by 2 mL/hr every 15 to 60 minutes until a pattern of three contractions in 10 minutes is established. What is the priority nursing action for this patient? a. Increase the infusion of Pitocin every 30 to 60 minutes. b. Assess for changes in the patient’s cervix every 2 hours. c. Obtain a reactive non–stress test prior to starting the infusion. d. Determine the fetal heart rate baseline for 30 minutes prior to starting the infusion. Cervical assessment estimates whether the cervix is favorable for induction. The Bishop scoring system is used to estimate cervical readiness for labor with five factors—cervical dilation, effacement, consistency, position, and fetal station. Vaginal birth is more likely to result if the Bishop score is higher than 8. This patient’s Bishop score is low and she is at increased risk for an operative birth. Titration of Pitocin is at the judgment of the RN. A slower infusion of Pitocin allows more time for her body to adapt to the Pitocin and increases her potential for a nonoperative birth. Pitocin is a rapid-acting drug with an onset of 1 minute, duration of 30 minutes, and a half-life of 12 to 17 minutes. Cervical assessment is completed on an as-needed basis and is not scheduled. Assuring fetal well-being is important and can be determined by variability in the FHR baseline. A reactive non–stress test is not necessary prior to infusion. Establishing a baseline FHR prior to induction is a standard of care. 326 A patient who is a 2-1-0-0-1 at 34 weeks’ gestation is interested in a vaginal birth after cesarean section (VBAC) and asks the nurse about this possibility. Which reason for her primary cesarean section would indicate to the nurse that the patient should be discouraged from pursuing this option? a. Transverse lie b. Prolapsed cord c. Placenta previa d. Cephalopelvic disproportion (CPD) A prior cesarean birth alone is not an indication for another cesarean birth for most women. Many women will choose repeat cesarean rather than a trial of labor even if they are appropriate candidates for VBAC because of the small, but real, added risk for uterine rupture. For other women, trying to deliver their next baby vaginally—whether successful or not—is important to them. Cephalopelvic disproportion is a condition in which fetal size exceeds the size of the pelvis. In cases of true CPD, the probability of the second fetus being smaller is slim and a repeat cesarean section is warranted. The remaining indications for the primary cesarean section do not relate to fetal size and a VBAC may be considered. 327 Which adverse effects can be seen in response to administration of oxytocin (Pitocin) for induction of labor? (Select all that apply.) a. Maternal hyponatremia b. Uterine tachysystole c. Maternal hypotension d. Reassuring fetal heart pattern e. Decreased variability on fetal tracing The administration of Pitocin can lead to a decrease in maternal serum sodium levels because of water intoxication. With regard to uterine effects, Pitocin can cause hyperstimulation or uterine tetany to occur, along with maternal hypotension. In terms of fetal response, Pitocin administration can lead to a nonreassuring fetal heart rate pattern manifested as bradycardia, tachycardia, and/or late decelerations and a decrease in variability, resulting in fetal compromise. 328 Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.) a. Fetal death b. Post-term pregnancy c. Rupture of membranes at or near term d. Convenience of the client or her health care provider e. Chorioamnionitis (inflammation of the amniotic sac) Fetal death, post-term pregnancy, rupture of members, and chorioamnionitis are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for convenience of the client or her provider are not recommended; however, they have become common. Factors such as rapid labors and living a long distance from a health care facility may be a valid reason in such a circumstance. 329 The nurse is planning care for a client who just received 25 mcg of misoprostol (Cytotec) vaginally to ripen the cervix. Which interventions should the nurse plan to implement? (Select all that apply.) a. Assist the client to the bathroom. b. Position the client in a high Fowler position. c. Assess the uterus for excessive contractions. d. Monitor the fetal heart rate for at least 30 minutes. . The FHR should be monitored for at least 30 minutes for changes and the uterus should be assessed for excessive contractions. To reduce leakage, the woman should lie flat for 15 to 20 minutes after the gel form of prostaglandin is inserted. The client should not be assisted to the bathroom immediately or placed in a high Fowler position (head of bed up 90 degrees). 330 A client is scheduled for an external cephalic version (ECV). Which should the nurse prepare to implement? (Select all that apply.) a. Initiation of an intravenous (IV) line b. Obtaining a baseline fetal monitoring pattern c. Administration of an oxytocin (Pitocin) infusion as prescribed d. Planning to observe the client and fetus for 1 hour after the procedure e. Administration of an Rh immunoglobulin after the procedure to Rh-positive clients Preparation for an ECV includes starting an IV line for possible drug administration or fluid resuscitation if the FHR is not reassuring, fetal monitoring to obtain baseline values, and observing the client and fetus for 1 hour after the procedure. The nurse administers a tocolytic drug such as terbutaline not an oxytocin. Rh immunoglobulin is given only if the client is Rh- negative 331 A client asks the nurse, “What can I do to avoid an episiotomy during birth?” Which responses should the nurse give? (Select all that apply). a. “Using the lithotomy position during pushing may be beneficial.” b. “Using prolonged breath-holding when pushing may help stretch the tissue.” c. “Beginning at 36 weeks, a daily 10-minute perineal massage may help stretch the tissue.” d. “Using an open glottis technique when pushing can promote gradual perineal stretching.” e. “Delaying pushing until the urge is felt can gradually distend the soft tissues of the pelvic floor.” Daily perineal massage and stretching by the woman from 36 weeks until birth has been shown to reduce the risk for perineal trauma during birth. Pushing with an open glottis technique rather than prolonged breath-holding when pushing promotes gradual perineal stretching. Delaying pushing until the urge is felt gradually distends the soft tissues of the pelvic floor. An upright position while pushing promotes gradual stretching of the woman’s perineum, not the lithotomy position. 332 An infant of a diabetic mom arrives in the nursery unit for observation. The infant is term at 38 weeks’ gestation and weighs 10 pounds. The maternal hemoglobin A1c level is noted at 10%. Which findings would the nurse suspect as being present? (Select all that apply.) a. Fetus is jittery, temperature is decreased b. Nasal flaring and retractions c. Slight jaundice noted on blanching of nose d. Calcium level of 10 mg/dL The most common complications with regard to fetal presentation in the context of maternal preexisting diabetes are hypoglycemia, hypokalemia, hyperbilirubinemia, and respiratory distress syndrome. Maternal hemoglobin A1c levels indicate that glycemic control has not been maintained, so the fetus is at risk to develop complications. 333 The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action? a. Ask the patient when she last had anything to eat or drink. b. Take a culture of the lesions to verify the involved organism. c. Ask the patient if she has had unprotected sex since her outbreak. d. Use electronic fetal surveillance to determine a baseline fetal heart rate. A cesarean birth is recommended for women with active lesions in the genital area, whether recurrent or primary, at the time of labor. The patient’s dietary intake is needed to prepare for surgery. This patient is in active labor and the fetus is at risk for infection if the membranes rupture. The health care provider needs to be notified, and a cesarean section needs to be performed as soon as possible. There is no need to validate the infection because the patient is well aware of the symptoms of an active infection. Although transmission to sexual partners is valid information, it is not necessary information in an urgent situation such as depicted in this scenario. Electronic fetal surveillance is the standard of care. 334 The results of a pregnant patient’s glucose tolerance test (GTT) were 158 mg/dL. What is the next test that the nurse will include in the patient’s teaching plan? a. Urinalysis b. Amniocentesis c. Nonstress test d. Oral glucose tolerance test (OGTT) If the blood glucose concentration for a GTT is 140 mg/dL or greater, a 3-hour oral glucose tolerance test is recommended. The woman must fast from midnight on the day of the test. After a fasting plasma glucose level is determined, the woman should ingest 100 g of oral glucose solution. Plasma glucose levels are then determined at 1, 2, and 3 hours. Gestational diabetes is the diagnosis if the fasting blood glucose level is abnormal. 335 Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality? a. Rubella b. Cytomegalovirus (CMV) c. Syphilis d. HIV Transmission of congenital rubella causes serious complications in the fetus that may manifest as cataracts, cardiac defects, microcephaly, deafness, intrauterine growth restriction (IUGR), and developmental delays. 336 Which client teaching instructions are necessary for a pregnant client who is to undergo a glucose challenge test (GCT) as part of a routine pregnancy treatment plan? a. Consume a low-fat diet for 48 hours prior to testing. b. Fast for 12 hours prior to testing. c. There are no dietary restrictions prior to testing. d. Consume a consistent carbohydrate diet (60 g) prior to testing. For a GCT, there are no dietary restrictions and fasting is not required. Testing is done from 24 to 28 weeks for the general pregnant population. 337 A client who has type 2 diabetes is pregnant with her second child. She was not diagnosed with diabetes until after her first pregnancy. Past obstetric history is unremarkable—spontaneous vaginal birth of a male weighing 7 pounds, 15 ounces. The client is now concerned over what will happen during this subsequent pregnancy as a result of her disease process. What impact could the disease process have on her upcoming birth? a. Client will not be able to receive an epidural for pain management. b. Client will not be able to have a vaginal birth. c. A planned birth will be instituted by her health care provider. d. It is likely that she will deliver a fetus who is small for gestational age (SGA). Because of the presence of diabetes as a concurrent disease, the client will be closely monitored and a planned birth will be instituted to improve health outcomes for mother and fetus. Epidurals can be administered to obstetric clients who are diabetics. Although there is an increased risk for macrosomia and dystocia, the client will be prospectively managed and may still be able to have a vaginal birth. Because of the presence of diabetes as a concurrent disease, it is more likely that she will deliver a macrosomic infant who would be large for gestational age (LGA). 338 A client, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her? a. Her two children should be treated with acyclovir before she goes home from the hospital. b. The baby will acquire immunity from her and will not be susceptible to chickenpox. c. The children can visit their mother and baby in the hospital as planned but must wear gowns and masks. d. She must make arrangements to stay somewhere other than her home until the children are no longer contagious. Varicella (chickenpox) is highly contagious. Although the baby inherits immunity from the mother, it would not be safe to expose either the mother or the baby. Acyclovir is used to treat varicella pneumonia. The baby is already born and has received the immunity. If the mother never had chickenpox, she cannot transmit the immunity to the baby. Varicella infection occurring in a newborn may be life threatening. 339 Antiinfective prophylaxis is indicated for a pregnant client with a history of mitral valve stenosis related to rheumatic heart disease because the client is at risk of developing: a. hypertension. b. postpartum infection. c. bacterial endocarditis. d. upper respiratory infections. Because of vegetations on the leaflets of the mitral valve and the increased demands of pregnancy, the client is at greater risk of bacterial endocarditis. Pulmonary hypertension may occur with mitral valve stenosis, but antiinfective medications will not prevent it from occurring. Women with cardiac problems must be observed for possible infections during the postpartum period but are not given prophylactic antibiotics to prevent them. Women are not put on prophylactic antibiotics to prevent upper respiratory infections. 340 Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy? a. Cardiomyopathy b. Mitral valve prolapse c. Rheumatic heart disease d. Congenital heart disease Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases will produce pulmonary hypertension or endocarditis during pregnancy. 341 When a pregnant client with diabetes experiences hypoglycemia while hospitalized, which should the nurse have the client do? a. Eat a candy bar. b. Eat six saltine crackers or drink 8 oz of milk. c. Drink 4 oz of orange juice followed by 8 oz of milk. d. Drink 8 oz of orange juice with 2 teaspoons of sugar added. Crackers provide carbohydrates in the form of polysaccharides. A candy bar provides only monosaccharides. Milk is a disaccharide and orange juice is a monosaccharide. This will help increase the blood sugar level but will not sustain it. Orange juice and sugar will increase the blood sugar level but will not provide a slow-burning carbohydrate to sustain it. 342 Which disease process improves during pregnancy? a. Epilepsy b. Bell’s palsy c. Rheumatoid arthritis d. Systemic lupus erythematosus (SLE) Although the reason is unclear, marked improvement is seen with rheumatoid arthritis in pregnancy. Most women relapse 6 weeks to 6 months postpartum. With epilepsy, the effect of pregnancy is variable and unpredictable. Seizures may increase, decrease, or remain the same. Bell’s palsy was thought to be caused by a virus three times more common during pregnancy and generally occurring in the third trimester. The client with SLE can have a normal pregnancy but must be treated as high risk because 50% of all births will be premature. Pregnancy can exacerbate SLE. 343 Which factor is most important in diminishing maternal, fetal, and neonatal complications in a pregnant client with diabetes? a. Evaluation of retinopathy by an ophthalmologist b. The client’s stable emotional and psychological status c. Degree of glycemic control before and during the pregnancy d. Total protein excretion and creatinine clearance within normal limit [Show More]

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