NURS 2863 Maternity Exam 2 Questions & Answers Already Graded A

NURS 2863 Maternity Exam 2 Questions & Answers A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: A) weight gain of 1 to 3 lbs. B) quickening. C) fatigue and lethargy. D) bloody show. The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: A) progressive uterine contractions with cervical change. B) lightening. C) rupture of membranes. D) passage of the mucous plug (operculum). On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A) The fetal presenting part is 1 cm above the ischial spines. B) Effacement is 4 cm from completion. C) Dilation is 50% completed. D) The fetus has achieved passage through the ischial spines. In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: A) The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. B) Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C) Having the woman point her toes reduces leg cramps. D) The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. The nurse knows that the second stage of labor, the descent phase, has begun when: A) the amniotic membranes rupture. B) The cervix cannot be felt during a vaginal examination. C) The woman experiences a strong urge to bear down. D) The presenting part is below the ischial spines. Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A) Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B) Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours C) Lull: no contractions; dilation stable; duration of 20 to 60 minutes D) Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? A) Semirecumbent B) Sitting C) Squatting D) Side-lying Concerning the third stage of labor, nurses should be aware that: A) the placenta eventually detaches itself from a flaccid uterus B) The duration of the third stage may be as short as 3 to 5 minutes C) it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface D) the major risk for women during the third stage is a rapid heart rate The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.) A) passenger. B) placenta. C) passageway. D) psychologic response. E) powers. F) position. Nurses can advise their patients that which of these signs precede labor? (Select all that apply.) A. A return of urinary frequency as a result of increased bladder pressure B. Persistent low backache from relaxed pelvic joints C. Stronger and more frequent uterine (Braxton Hicks) contractions D. A decline in energy, as the body stores up for labor E. Uterus sinks downward and forward in first-time pregnancies. The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.) A. Positive urine drug screen B. Blood glucose level of 78 mg/dL C. Increased systolic blood pressure during first stage D. Elevated white blood cell count E. Oral temperature of 99.8° F F. Respiratory rate of 10 breaths/min A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A. encourage the woman to breathe more slowly. B. help the woman breathe into a paper bag. C. turn the woman on her side. D. administer a sedative. A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A. Encourage her to empty her bladder. B. Decrease her intravenous (IV) rate to a keep vein-open rate. C. Turn the woman to the left lateral position or place a pillow under her hip. D. No action is necessary since a decrease in the woman's blood pressure is expected. A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: A. fentanyl (Sublimaze). B.promethazine (Phenergan). C. butorphanol tartrate (Stadol). D. nalbuphine (Nubain). A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A. counterpressure against the sacrum. B. pant-blow (breaths and puffs) breathing techniques. C. effleurage. D. biofeedback. Nurses should be aware of the difference experience can make in labor pain, such as: A. sensory pain for nulliparous women often is greater than for multiparous women during early labor. B. affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C. women with a history of substance abuse experience more pain during labor. D. multiparous women have more fatigue from labor and therefore experience more pain. With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: A. either hot or cold applications may provide relief, but they should never be used together in the same treatment. B. acupuncture can be performed by a skilled nurse with just a little training. C. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. D. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations. With regard to systemic analgesics administered during labor, nurses should be aware that: A. systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B. effects on the fetus and newborn can include decreased alertness and delayed sucking. C. IM administration is preferred over IV administration. D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic. After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A. visceral. B. referred. C. somatic. D. afterpain. When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A. Maternal blood pressure of 108/79 B. Maternal heart rate of 98 C. Respiratory rate of 14 breaths/min D. Fetal heart rate of 100 beats/min E. Minimal variability on a fetal heart monitor After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.) A. Keeping the head of bed elevated at all times B. Administration of oral analgesics C. Avoid caffeine D. Assisting with a blood patch procedure E. Frequent monitoring of vital signs When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: A. maternal hyperthyroidism. B. initiation of epidural anesthesia that resulted in maternal hypotension. C. maternal infection accompanied by fever. D. alteration in maternal position from semirecumbent to lateral. On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: A. describe the finding in the nurse's notes. B. reposition the woman onto her side. C. call the physician for instructions. D. administer oxygen at 8 to 10 L/min with a tight face mask. A. describe the finding in the nurse's notes Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? A. FHR does not change as a result of fetal activity. B. Average baseline rate ranges between 100 and 140 beats/min. C. Mild late deceleration patterns occur with some contractions. D. Variability averages between 6 to 10 beats/min. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to: A. change the woman's position. B. stop the Pitocin. C. elevate the woman's legs. D. administer oxygen via a tight mask at 8 to 10 L/min. You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? A. Notify nursery nurse of imminent delivery. B. Insert a Foley catheter. C. Start oxytocin (Pitocin). D. Notify the primary health care provider immediately (HCP). When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: A. the examiner's hand should be placed over the fundus before, during, and after contractions. B. the frequency and duration of contractions are measured in seconds for consistency. C. contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. D. the resting tone between contractions is described as either placid or turbulent. A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: A. narcotics. B. barbiturates. C. methamphetamines. D. tranquilizers. The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: A. change in position. B. oxytocin administration. C. regional anesthesia. D. intravenous analgesic. Fetal well-being during labor is assessed by: A. the response of the fetal heart rate (FHR) to uterine contractions (UCs). B. maternal pain control. C. accelerations in the FHR. D. an FHR greater than 110 beats/min. Which characteristic is associated with false labor contractions? A. Painless B. Decrease in intensity with ambulation C. Regular pattern of frequency established D. Progressive in terms of intensity and duration A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? A. "My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." B. "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." C. "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." D. "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage." The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is: A. severe postpartum headache. B. limited perception of bladder fullness. C. increase in respiratory rate. D. hypotension. When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: A. encouraging the woman to try various upright positions, including squatting and standing. B. telling the woman to start pushing as soon as her cervix is fully dilated. C. continuing an epidural anesthetic so that pain is reduced and the woman can relax. D. coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction. Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? A. The healthy newborn should be taken to the nursery for a complete assessment. B. After drying, the infant should be given to the mother wrapped in a receiving blanket. C. Encourage skin-to-skin contact of mother and baby. D. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta. Which description of the phases of the second stage of labor is accurate? A. Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes B. Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes C. Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Which test is performed to determine if membranes are ruptured? A. Urine analysis B. Fern test C. Leopold maneuvers D. Artificial Rupture of Membranes (AROM) A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: A. "Don't worry about it. You'll do fine." B. "It's normal to be anxious about labor. Let's discuss what makes you afraid." C. "Labor is scary to think about, but the actual experience isn't." D. "You may have an epidural. You won't feel anything." Vaginal examinations should be performed by the nurse under which of these circumstances. (Select all that apply.) A. An admission to the hospital at the start of labor B. When accelerations of the fetal heart rate (FHR) are noted C. On maternal perception of perineal pressure or the urge to bear down D. When membranes rupture E. When bright, red bleeding is observed For the labor nurse, care of the expectant mother begins with which situations? (Select all that apply.) A. The onset of progressive, regular contractions B. The bloody, or pink, show C. The spontaneous rupture of membranes D. Formulation of the woman's plan of care for labor E. Moderately painful contractions A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to: A. assess the fetal heart rate (FHR) pattern. B. perform a vaginal examination. C. inspect the characteristics of the fluid. D. assess maternal temperature. A woman is evaluated to be using an effective bearing-down effort if she: A. begins pushing as soon as she is told that her cervix is fully dilated and effaced. B. takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. C. uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. D. continues to push for short periods between uterine contractions throughout the second In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information? A. "Because this is a repeat procedure, you are at the lowest risk for complications." B. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." C. "Because this is your second cesarean birth, you will recover faster." D. "You will not need preoperative teaching because this is your second cesarean birth." For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? A. Fetal heart rate of 116 beats/min B. Cervix dilated 2 cm and 50% effaced C. Score of 8 on the biophysical profile D. One fetal movement noted in 1 hour of assessment by the mother A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? A. Place the woman in the knee-chest position. B. Cover the cord in a sterile towel saturated with warm normal saline. C. Prepare the woman for a cesarean birth. D. Start oxygen by face mask. A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: A. uterine contractions occurring every 8 to 10 minutes B. a fetal heart rate (FHR) of 180 with absence of variability C. the client needing to void D. rupture of the client's amniotic membranes With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: A. the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. B. there are no important maternal (as opposed to fetal) contraindications. C. its most important function is to afford the opportunity to administer antenatal glucocorticoids. D. if the client develops pulmonary edema while on tocolytics, IV fluids should be given. With regard to dysfunctional labor, nurses should be aware that: A. women who are underweight are more at risk. B. women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted. C. hypertonic uterine dysfunction is more common than hypotonic dysfunction. D. abnormal labor patterns are most common in older women. A nurse providing care to a woman in labor should be aware that cesarean birth: A. is declining in frequency in the United States. B. is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier clients do. C. is performed primarily for the benefit of the fetus. D. can be either elected or refused by women as their absolute legal right. Which statement is most likely to be associated with a breech presentation? A. Least common malpresentation B. Descent is rapid C. Diagnosis by ultrasound only D. High rate of neuromuscular disorders A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.) A. Estriol is found in maternal saliva. B. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. C. Fetal fibronectin is present in vaginal secretions. D. The cervix is effacing and dilated to 2 cm. E. Fetal heart rate of 150 beats/minute The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.) A. Unstable coronary artery disease B. Previous cesarean birth C. Placenta previa D. Initial blood pressure of 132/87 E. History of three spontaneous abortions Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: A. return to pre-pregnant weight is usually achieved by the end of the postpartum period. B. fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb weight loss. C. the expected weight loss immediately after birth averages about 11 to 13 lbs. D. lactation will inhibit weight loss since caloric intake must increase to support milk production. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: A. wear a snug, supportive bra. B. allow warm water to soothe the breasts during a shower. C. express milk from breasts occasionally to relieve discomfort. D. place absorbent pads with plastic liners into her bra to absorb leakage. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A. urinary tract infection. B. excessive uterine bleeding. C. a ruptured bladder. D. bladder wall atony. What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." C. "I will not have a menstrual cycle for 6 months after childbirth." D. "My first menstrual cycle will be heavier than normal and then will be light for several months after." With regard to afterbirth pains, nurses should be aware that these pains are: A. caused by mild, continual contractions for the duration of the postpartum period. B. more common in first-time mothers. C. more noticeable in births in which the uterus was overdistended. D. alleviated somewhat when the mother breastfeeds. Postbirth uterine/vaginal discharge, called lochia: A. is similar to a light menstrual period for the first 6 to 12 hours. B. is usually greater after cesarean births.