NURSING 366 Practice Exam Questions with Answers

NURSING 366 Practice Exam Questions with Answers A 40­year­old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? A Biophysical profile B Amniocentesis C Maternal serum alpha­fetoprotein (MSAFP) D Transvaginal ultrasound ­ D A biophysical profile is a method of biophysical assessment of fetal well­being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal). An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women whose thick abdominal layers cannot be penetrated adequately with the abdominal approach. A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A sometimes uses vibroacoustic stimulation. B is an invasive test; however, contractions are stimulated. C is considered negative if no late decelerations are observed with the contractions. D is more effective than nonstress test (NST) if the membranes have already been ruptured. ­ C Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by IV oxytocin but not if by nipple stimulation. No late decelerations indicate a positive CST. CST is contraindicated if the membranes have ruptured. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? A Doppler blood flow analysis B Contraction stress test (CST) C Amniocentesis D Daily fetal movement counts ­ A Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high­risk pregnancies because of intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR. Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that: A chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis. B screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects. C percutaneous umbilical blood sampling (PUBS) is one of the quad-screen tests for Down syndrome. D MSAFP is a screening tool only; it identifies candidates for more definitive procedures. - D CVS does provide a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. MSAFP screening is recommended for all pregnant women. MSAFP, not PUBS, is part of the quad-screen tests for Down syndrome. This is correct. MSAFP is a screening tool, not a diagnostic tool. Further diagnostic testing is indicated after an abnormal MSAFP. The nurse is reviewing lab values to determine Rh incompatibility between mother and fetus. The nurse should assess which specific lab result? A Indirect Coombs test B Hemoglobin level C hCG level D Maternal serum alpha-fetoprotein (MSAFP) - A The indirect Coombs test is a screening tool for Rh incompatibility. If the maternal titer for Rh antibodies is greater than 1:8, amniocentesis for determination of bilirubin in amniotic fluid is indicated to establish the severity of fetal hemolytic anemia. Hemoglobin reveals the oxygen carrying capacity of the blood. hCG is the hormone of pregnancy. Maternal serum alpha-fetoprotein (MSAFP) levels are used as a screening tool for NTDs in pregnancy The nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function? A Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics B Prepare the woman for delivery by cesarean section since this is the recommended delivery method to sustain hemodynamics C Encourage the woman to avoid the use of narcotics or epidural regional analgesia since this alters cardiac function D Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling - A The side-lying position with the head and shoulders elevated helps to facilitate hemodynamics during labor. A vaginal delivery is the preferred method of delivery for a woman with cardiac disease as it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. The use of the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow. Maternal and neonatal risks associated with gestational diabetes mellitus are: A maternal premature rupture of membranes and neonatal sepsis. B maternal hyperemesis and neonatal low birth weight. C maternal preeclampsia and fetal macrosomia. D maternal placenta previa and fetal prematurity - C Premature rupture of membranes and neonatal sepsis are not risks associated with gestational diabetes. Hyperemesis is not seen with gestational diabetes, nor is there an association with low birth weight of the infant. Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia. Placental previa and subsequent prematurity of the neonate are not risks associated with gestational diabetes. In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: A mother's age. B number of years since diabetes was diagnosed. C amount of insulin required prenatally. D degree of glycemic control during pregnancy. - D Although advanced maternal age may pose some health risks, for the woman with pregestational diabetes the most important factor remains the degree of glycemic control during pregnancy. The number of years since diagnosis is not as relevant to outcomes as the degree of glycemic control. The key to reducing risk in the pregestational diabetic woman is not the amount of insulin required but rather the level of glycemic control. Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: A with good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. B the most important cause of perinatal loss in diabetic pregnancy is congenital malformations. C infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. D at birth, the neonate of a diabetic mother is no longer at any greater risk. - B Even with good control, sudden and unexplained stillbirth remains a major concern. Congenital malformations account for 30% to 50% of perinatal deaths. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities. A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: A oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. B dietary modifications and insulin are both required for adequate treatment. C glucose levels are monitored by testing urine 4r times a day and at bedtime. D dietary management involves distributing nutrient requirements over three meals and two or three snacks. - D Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative. Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis. During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of: A euglycemia. B rheumatic fever. C pneumonia. D cardiac decompensation. - D Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not present with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation. Symptoms of cardiac decompensation may appear abruptly or gradually. Thalassemia is a relatively common anemia in which: A an insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs). B RBCs have a normal life span but are sickled in shape. C folate deficiency occurs. D there are inadequate levels of vitamin B12 . - A Thalassemia is a hereditary disorder that involves the abnormal synthesis of the á or â chains of hemoglobin. An insufficient amount of hemoglobin is produced to fill the RBCs. This is the underlying description for sickle cell anemia. Folate deficiency is the most common cause of megaloblastic anemias during pregnancy. B12 deficiency must also be considered if the pregnant woman presents with anemia. From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks: A in the first trimester. B between 24 to 36 weeks of gestation. C during the last 4 weeks of pregnancy. D immediately postpartum. - B Women often have few symptoms of asthma during the first trimester. The severity of symptoms peaks between 24 and 36 weeks of gestation. Asthma appears to be associated with intrauterine growth restriction and preterm birth. During the last 4 weeks of pregnancy symptoms often subside. The period between 24 and 36 weeks of pregnancy is associated with the greatest severity of symptoms. Issues have often resolved by the time the woman delivers. A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often: A orthopnea. B decreasing energy levels. C moist frequent cough and frothy sputum. D crackles (rales) at the bases of the lungs on auscultation. - B Orthopnea is a finding that appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Decreasing energy level (fatigue) is an early finding of heart failure. Care must be taken to recognize it as a warning rather than a typical change of the third trimester. Cardiac decompensation is most likely to occur early in the third trimester, during childbirth, and during the first 48 hours following birth. A moist, frequent cough appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Crackles and rales appear later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions? A "I will not experience mood swings since I was only at 10 weeks of gestation." B "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months." C "I should eat foods that are high in iron and protein to help my body heal." D "I should expect the bleeding to be heavy and bright red for at least 1 week." - C After a miscarriage a woman may experience mood swings and depression from the reduction of hormones and the grieving process. Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months. A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss. The woman should not experience bright red, heavy, profuse bleeding; this should be reported to the health care provider. A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: A a sleepy, sedated affect. B a respiratory rate of 10 breaths/min. C deep tendon reflexes of 2+. D absent ankle clonus. - B Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding. A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if: A blood pressure is reduced to prepregnant baseline. B seizures do not occur. C deep tendon reflexes become hypotonic. D diuresis reduces fluid retention. - B A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration. A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A hydralazine. B magnesium sulfate bolus . C diazepam. D calcium gluconate. - A Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity. The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: A bleeding. B intense abdominal pain. C uterine activity. D cramping. - B Bleeding may be present in varying degrees for both placental conditions. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Uterine activity may be present with both placental conditions. Cramping is a form of uterine activity that may be present in both placental conditions. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: A eclamptic seizure. B rupture of the uterus. C placenta previa. D placental abruption. - D Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? A Administration of blood B Preparation of the woman for invasive hemodynamic monitoring C Restriction of intravascular fluids D Administration of steroids - A Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because this can contribute to more areas of bleeding. Management of DIC includes volume replacement, not volume restriction. Steroids are not indicated for the management of DIC. Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? A Prepare the woman for a dilation and curettage (D&C). B Place the woman on bed rest for at least 1 week and reevaluate. C Prepare the woman for an ultrasound and blood work. D Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month. - C D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy. A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for: A hemorrhage. B infection. C urinary retention. D thrombophlebitis. - A Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention than with a normally implanted placenta. There is no greater risk for thrombophlebitis than with a normally implanted placenta. 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 3lbs. B quickening. C fatigue and lethargy. D bloody show. - D Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct. Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens. 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). - A Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer 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. - A Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1. 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. - D Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of potentially unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. 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. - C Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation. 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 - B The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes. 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 - C A. A semirecumbent position does not assist in increasing the size of the pelvic outlet. B. Although sitting may assist with fetal descent, this position does not increase the size of the pelvic outlet. C. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. D. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet. 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 - B A. The placenta cannot detach itself from a flaccid (relaxed) uterus. B. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. C. Which surface of the placenta comes out first is not clinically important. D. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases. 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. - B Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension. 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. - C Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken. 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 Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. 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. - A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support. 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. - A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. 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. - C Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. The woman and her partner should experiment with massage before labor to see what might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body. 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. - B Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased 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. - B Visceral pain is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor. 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. - B Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR pattern. 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 An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix. These actions would be implemented when non-reassuring or ominous changes are noted. These actions would be implemented when non-reassuring or ominous changes are noted. These actions would be implemented when non-reassuring or ominous changes are noted. 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. - D FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well- oxygenated fetus with a functioning autonomic nervous system. 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. - B The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action. 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). - D This is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or non-reassuring pattern, a cesarean section may be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately. 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 The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed. 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. - A Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration may reduce maternal cardiac output. Regional anesthesia may reduce maternal cardiac output. Intravenous analgesic may reduce maternal cardiac output. 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. - A Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being. 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 - B True labor contractions are painful. Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor. 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." - D These are acceptable requests during labor and delivery. These are acceptable requests during labor and delivery. These are acceptable requests during labor and delivery. Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low-risk pregnancy and as long as labor is progressing normally. 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. - D Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic because it would be with a low spinal (saddle block) anesthetic. Limited perception of bladder fullness is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure. 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. - A Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed- glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia. 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. - C Although this is the practice in many facilities, it is neither evidence-based nor supportive of family-centered care. This is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed skin to skin. The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. The father or support person is likely anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin and breastfeeding has been initiated. 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 D Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes - C The latent phase is the lull, or "laboring down," period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The transition phase is the final phase in the second stage of labor; contractions are strong and painful. 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) - B A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook. 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." - B This statement negates the woman's fears and is not therapeutic. This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool. This statement negates the woman's fears and offers a false sense of security. This statement is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural. 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 The first nursing action after the membranes are ruptured is to check the FHR. Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy). These are all important and should be done after the FHR and pattern are assessed. These are all important and should be done after the FHR and pattern are assessed. These are all important and should be done after the FHR and pattern are assessed. 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 stage of labor. - B Bearing-down efforts should begin during the active-descent phase of the second stage of labor when the urge to bear down (Fresno reflex) is perceived. Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal. Pushing gently between contractions is only advised when the fetal head is being delivered. 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." - B This statement is not accurate. Maternal and fetal risks are associated with every cesarean section. This statement is the most appropriate. This statement is not accurate. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure. 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 - D A fetal heart rate of 116 beats/min is a normal finding at 42 weeks of gestation. Cervical dilation of 2 cm with 50% effacement is a normal finding in a 42-week gestation woman. A score of 8 on the BPP is a normal finding in a 42-week gestation pregnancy. Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. 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 A. The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. B. If the cord is protruding from the vagina, it may be covered with a sterile towel soaked in saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing priority. C. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete. D. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. This intervention should be initiated after pressure is relieved on the cord. Not only should the woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers to lift the presenting part off the cord. 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 - B The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. This FHR is non-reassuring. The oxytocin should be immediately discontinued and the physician should be notified. This is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is non-reassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the client's membranes have ruptured. 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. - C Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Tocolytic-induced edema can be caused by IV fluids. 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. - B Short women more than 30 lbs overweight are more at risk for dysfunctional labor. Precipitous labor lasts less than 3 hours. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years of age. 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. - C Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear. 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 - D Breech is the most common malpresentation affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as is the fetal head. Diagnosis is made by abdominal palpation and vaginal examination. It is confirmed by ultrasound. Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus. 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 prepregnant 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. - C Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6- week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 lbs. The expected weight loss immediately following delivery is 11 to 13 lbs, followed by a gradual decrease and a return to prepregnancy weight in 2 to 3 months. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process. 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 A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking. 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. - B A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. Excessive bleeding can occur immediately after birth if the bladder becomes distended, because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding. 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." - B She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. This is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. 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. - C The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus. Breastfeeding intensifies afterbirth pain because it stimulates contractions.