NUR 158 Test #3 Questions With Complete Solutions
A client in the active phase of the first stage of labor begins to
tremble, becomes very tense during contractions, and is quite
irritable, saying repeatedly, 'I can't take this a minute longer.'
Which is the best explanation for this behavior?
A) There was no preparation for labor.
B) She needs an analgesic for pain.
C) She is entering the transition phase of labor.
D) Hypertonic uterine contractions are developing.
C) She is entering the transition phase of labor.
Rationale
The contractions become stronger, last longer, and occur
erratically during the transition phase; the intervals between
contractions become shorter than the contractions themselves;
the client needs to apply a great deal of concentration and effort
to pace her breathing with each contraction. Even clients who
have been adequately prepared will experience these behaviors
during the transition phase of the first stage of labor.
Administration of an analgesic at this time may reduce the
effectiveness of labor and depress the fetus. There is no
indication that the contractions are hypertonic.
Which of these presentations would indicate that the nurse
should direct a primipara to call a healthcare provider?
,A) Bloody show or back pressure occurring with no contractions
B) Irregular contractions coming 10 minutes apart
C) Rupture of membranes or contractions 5 minutes apart
D) Contractions 12 minutes apart and lasting about 30 seconds
C) Rupture of membranes or contractions 5 minutes apart
Rationale
When the membranes rupture, the potential for infection is
increased, and when the contractions are 5 to 8 minutes apart,
they are usually of sufficient force to warrant professional
supervision. Bloody show and back pressure may be early signs
of labor or signs of posterior fetal position; however, it is too
early to notify the health care provider. Irregular contractions
coming 10 minutes apart and contractions 12 minutes apart and
lasting about 30 seconds indicate that it is too soon in the labor
process to call the health care provider; the client should remain
with her family and keep moving around at home.
The electronic fetal monitor on a client receiving an infusion of
oxytocin (Pitocin) displays contractions every 2 minutes and
lasting 95 seconds. Which is the appropriate nursing action?
A) Stop the oxytocin (Pitocin) infusion.
B) Administer oxygen at 8 to 10 L/min.
C) Increase the main line fluid delivery rate to 150 mL/hr.
D) Prepare the client for insertion of an intrauterine pressure
catheter.
,A) Stop the oxytocin (Pitocin) infusion.
Rationale
The contraction pattern indicates hyperstimulation of the uterus.
Stopping the oxytocin (Pitocin) infusion permits relaxation of
the uterus and perfusion of the placenta. Oxygen cannot reach
the placenta until the uterus is relaxed, so administering oxygen
will not help. Increasing the rate of delivery of the main line
fluid does not affect hyperstimulation of the uterus. Insertion of
an intrauterine pressure catheter will only provide measurement
of the internal uterine pressure and will not affect uterine
contractions.
Which statement indicates a client understands the meaning of
having a reactive nonstress test?
A) Normal because of increases in fetal heart rate (FHR) with
fetal movement
B) Abnormal because of a decrease in FHR between
contractions
C) Abnormal because of variability in FHR with each
contraction
D) Normal because the FHR remained unchanged with maternal
movement
A) Normal because of increases in fetal heart rate (FHR) with
fetal movement
Rationale
A reactive nonstress test is an expected finding because there are
, 2 or more increases in FHR greater than 15 beats/min associated
with fetal movement; it suggests fetal well-being. There are no
uterine contractions during a nonstress test. Maternal movement
has no bearing on nonstress test readings; fetal movements and
FHR are monitored.
Where is the presenting part of the fetus when station is -1?
A) 1 cm above the ischial spines
B) 1 cm below the ischial spines
C) Visible at the vaginal opening
D) At the level of the ischial spines
A) 1 cm above the ischial spines
Rationale
Station -1 signifies that the fetal head is 1 cm above the ischial
spines and has not reached the vaginal canal. When the fetal
head is 1 cm below the ischial spines, it is at station +1. When
the fetal head is visible at the vaginal opening, it is at station +4.
When the fetal head is level with the ischial spines, it is at
station 0.
Which response would the nurse give to a client who asks what
having a fetus in longitudinal lie means in relation to her labor
and birth of the baby?
A) 'A vaginal birth is possible.'
B) 'We're anticipating a cesarean delivery.'
A client in the active phase of the first stage of labor begins to
tremble, becomes very tense during contractions, and is quite
irritable, saying repeatedly, 'I can't take this a minute longer.'
Which is the best explanation for this behavior?
A) There was no preparation for labor.
B) She needs an analgesic for pain.
C) She is entering the transition phase of labor.
D) Hypertonic uterine contractions are developing.
C) She is entering the transition phase of labor.
Rationale
The contractions become stronger, last longer, and occur
erratically during the transition phase; the intervals between
contractions become shorter than the contractions themselves;
the client needs to apply a great deal of concentration and effort
to pace her breathing with each contraction. Even clients who
have been adequately prepared will experience these behaviors
during the transition phase of the first stage of labor.
Administration of an analgesic at this time may reduce the
effectiveness of labor and depress the fetus. There is no
indication that the contractions are hypertonic.
Which of these presentations would indicate that the nurse
should direct a primipara to call a healthcare provider?
,A) Bloody show or back pressure occurring with no contractions
B) Irregular contractions coming 10 minutes apart
C) Rupture of membranes or contractions 5 minutes apart
D) Contractions 12 minutes apart and lasting about 30 seconds
C) Rupture of membranes or contractions 5 minutes apart
Rationale
When the membranes rupture, the potential for infection is
increased, and when the contractions are 5 to 8 minutes apart,
they are usually of sufficient force to warrant professional
supervision. Bloody show and back pressure may be early signs
of labor or signs of posterior fetal position; however, it is too
early to notify the health care provider. Irregular contractions
coming 10 minutes apart and contractions 12 minutes apart and
lasting about 30 seconds indicate that it is too soon in the labor
process to call the health care provider; the client should remain
with her family and keep moving around at home.
The electronic fetal monitor on a client receiving an infusion of
oxytocin (Pitocin) displays contractions every 2 minutes and
lasting 95 seconds. Which is the appropriate nursing action?
A) Stop the oxytocin (Pitocin) infusion.
B) Administer oxygen at 8 to 10 L/min.
C) Increase the main line fluid delivery rate to 150 mL/hr.
D) Prepare the client for insertion of an intrauterine pressure
catheter.
,A) Stop the oxytocin (Pitocin) infusion.
Rationale
The contraction pattern indicates hyperstimulation of the uterus.
Stopping the oxytocin (Pitocin) infusion permits relaxation of
the uterus and perfusion of the placenta. Oxygen cannot reach
the placenta until the uterus is relaxed, so administering oxygen
will not help. Increasing the rate of delivery of the main line
fluid does not affect hyperstimulation of the uterus. Insertion of
an intrauterine pressure catheter will only provide measurement
of the internal uterine pressure and will not affect uterine
contractions.
Which statement indicates a client understands the meaning of
having a reactive nonstress test?
A) Normal because of increases in fetal heart rate (FHR) with
fetal movement
B) Abnormal because of a decrease in FHR between
contractions
C) Abnormal because of variability in FHR with each
contraction
D) Normal because the FHR remained unchanged with maternal
movement
A) Normal because of increases in fetal heart rate (FHR) with
fetal movement
Rationale
A reactive nonstress test is an expected finding because there are
, 2 or more increases in FHR greater than 15 beats/min associated
with fetal movement; it suggests fetal well-being. There are no
uterine contractions during a nonstress test. Maternal movement
has no bearing on nonstress test readings; fetal movements and
FHR are monitored.
Where is the presenting part of the fetus when station is -1?
A) 1 cm above the ischial spines
B) 1 cm below the ischial spines
C) Visible at the vaginal opening
D) At the level of the ischial spines
A) 1 cm above the ischial spines
Rationale
Station -1 signifies that the fetal head is 1 cm above the ischial
spines and has not reached the vaginal canal. When the fetal
head is 1 cm below the ischial spines, it is at station +1. When
the fetal head is visible at the vaginal opening, it is at station +4.
When the fetal head is level with the ischial spines, it is at
station 0.
Which response would the nurse give to a client who asks what
having a fetus in longitudinal lie means in relation to her labor
and birth of the baby?
A) 'A vaginal birth is possible.'
B) 'We're anticipating a cesarean delivery.'
