Pregnancy, Labor, Childbirth, Postpartum - At Risk Quiz
2022 with complete solution
A nurse applies fetal and uterine monitors to the abdomen of a client in active
labor. When the client has contractions, the nurse notes a 15 beats/min
deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is
the next nursing action?
Changing the maternal position
To prevent or stabilize a client in heroin withdrawal during labor, which
medication should be administered as ordered if the woman is nauseated,
vomiting, or did not receive her daily dose at a chemical dependence center?
Dolophine (Methadone)
A primigravida in whom placenta previa has already been diagnosed is admitted
with bright-red vaginal bleeding at 34 weeks' gestation. What is the nurse's initial
intervention?
Positioning the client in the side-lying position to ease pressure on the cervix
What should be included in the nursing care for a client at 41 weeks' gestation
who is to have a contraction stress test?
Having the client empty her bladder
A nurse is caring for a client who has been admitted with a tentative diagnosis of
placenta previa. What procedure does the nurse anticipate?
Ultrasound examination
A pregnant client comes to the emergency department because of vaginal
bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is
the best gauge for the client to use?
Amount of blood lost in relation to usual menstrual flow
Several hours after delivery, a new mother expresses ambivalence about her
infant. How will the nurse promote bonding between this mother and her
newborn?
Having the mother feed the infant
A client at term is admitted in active labor. She has tested positive for HIV. Which
intervention in the standard orders should the nurse question as a risk to the
fetus?
Internal fetal scalp electrode
A pregnant client with a history of preterm labor is at home on bedrest. What
instructions should a teaching plan for this client include?
Lie on the side with the head raised on a small pillow.
After a difficult labor a client gives birth to a 9-lb boy who dies shortly afterward.
That evening the client tearfully describes to the nurse her projected image of her
son and what his future might have been. What is the nurse's most therapeutic
response?
"It must be difficult to think of him now."
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation.
What does the nurse suspect precipitated this preterm labor?
Incompetent cervix
, A multipara whose membranes have ruptured is admitted in early labor.
Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal
station at −2. For what complication should the nurse assess when caring for this
client?
Prolapse of the umbilical cord
Which client is at risk for a postpartum infection?
A woman who required catheterization after voiding less than 75 mL
A nurse is concerned about a client's mother-infant bonding when on the first
postpartum day she is reluctant to:
Look at her newborn's face.
A client in labor, who is at term, is admitted to the birthing room. The fetus is in
the left occiput posterior position. The client's membranes rupture
spontaneously. What observation requires the nurse to notify the practitioner?
Greenish amniotic fluid
When entering the room of a client in active labor to answer the call light, the
nurse sees that she is ashen gray, dyspneic, and clutching her chest. What
should the nurse do after pressing the emergency light in the client's room?
Administer oxygen by facemask.
A client who had a cesarean birth is unable to void 3 hours after the removal of an
indwelling catheter. How can the nurse evaluate whether the client's bladder is
distended?
By palpating the client's suprapubic area gently
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about
how her pregnancy will affect her diet and insulin needs. How should the nurse
respond?
"Insulin dosage and dietary needs will be adjusted in accordance with the results of
blood glucose monitoring."
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During
the test, the client asks the nurse what it means when the fetal heart rate goes up
every time the fetus moves. What should the nurse consider before responding?
These accelerations are a sign of fetal well-being.
A client had a cesarean birth 4 hours ago. What is the major nursing intervention
at this time?
Relieving postoperative pain
A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and
60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood
from the vagina. The uterus is irritable on palpation and does not relax fully
between contractions. What is the initial nursing action?
Assessing the fetal heart rate, uterine activity, and blood pressure
A client with worsening preeclampsia is admitted to the high-risk unit, and the
nurse manager places her in a private room. A nonstimulating environment is
important for a client with increased cerebral irritability because it:
Decreases the probability of generalized seizures
What is the initial responsibility of a nurse teaching the pregnant adolescent?
Encouraging her to continue regularly scheduled prenatal care
2022 with complete solution
A nurse applies fetal and uterine monitors to the abdomen of a client in active
labor. When the client has contractions, the nurse notes a 15 beats/min
deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is
the next nursing action?
Changing the maternal position
To prevent or stabilize a client in heroin withdrawal during labor, which
medication should be administered as ordered if the woman is nauseated,
vomiting, or did not receive her daily dose at a chemical dependence center?
Dolophine (Methadone)
A primigravida in whom placenta previa has already been diagnosed is admitted
with bright-red vaginal bleeding at 34 weeks' gestation. What is the nurse's initial
intervention?
Positioning the client in the side-lying position to ease pressure on the cervix
What should be included in the nursing care for a client at 41 weeks' gestation
who is to have a contraction stress test?
Having the client empty her bladder
A nurse is caring for a client who has been admitted with a tentative diagnosis of
placenta previa. What procedure does the nurse anticipate?
Ultrasound examination
A pregnant client comes to the emergency department because of vaginal
bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is
the best gauge for the client to use?
Amount of blood lost in relation to usual menstrual flow
Several hours after delivery, a new mother expresses ambivalence about her
infant. How will the nurse promote bonding between this mother and her
newborn?
Having the mother feed the infant
A client at term is admitted in active labor. She has tested positive for HIV. Which
intervention in the standard orders should the nurse question as a risk to the
fetus?
Internal fetal scalp electrode
A pregnant client with a history of preterm labor is at home on bedrest. What
instructions should a teaching plan for this client include?
Lie on the side with the head raised on a small pillow.
After a difficult labor a client gives birth to a 9-lb boy who dies shortly afterward.
That evening the client tearfully describes to the nurse her projected image of her
son and what his future might have been. What is the nurse's most therapeutic
response?
"It must be difficult to think of him now."
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation.
What does the nurse suspect precipitated this preterm labor?
Incompetent cervix
, A multipara whose membranes have ruptured is admitted in early labor.
Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal
station at −2. For what complication should the nurse assess when caring for this
client?
Prolapse of the umbilical cord
Which client is at risk for a postpartum infection?
A woman who required catheterization after voiding less than 75 mL
A nurse is concerned about a client's mother-infant bonding when on the first
postpartum day she is reluctant to:
Look at her newborn's face.
A client in labor, who is at term, is admitted to the birthing room. The fetus is in
the left occiput posterior position. The client's membranes rupture
spontaneously. What observation requires the nurse to notify the practitioner?
Greenish amniotic fluid
When entering the room of a client in active labor to answer the call light, the
nurse sees that she is ashen gray, dyspneic, and clutching her chest. What
should the nurse do after pressing the emergency light in the client's room?
Administer oxygen by facemask.
A client who had a cesarean birth is unable to void 3 hours after the removal of an
indwelling catheter. How can the nurse evaluate whether the client's bladder is
distended?
By palpating the client's suprapubic area gently
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about
how her pregnancy will affect her diet and insulin needs. How should the nurse
respond?
"Insulin dosage and dietary needs will be adjusted in accordance with the results of
blood glucose monitoring."
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During
the test, the client asks the nurse what it means when the fetal heart rate goes up
every time the fetus moves. What should the nurse consider before responding?
These accelerations are a sign of fetal well-being.
A client had a cesarean birth 4 hours ago. What is the major nursing intervention
at this time?
Relieving postoperative pain
A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and
60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood
from the vagina. The uterus is irritable on palpation and does not relax fully
between contractions. What is the initial nursing action?
Assessing the fetal heart rate, uterine activity, and blood pressure
A client with worsening preeclampsia is admitted to the high-risk unit, and the
nurse manager places her in a private room. A nonstimulating environment is
important for a client with increased cerebral irritability because it:
Decreases the probability of generalized seizures
What is the initial responsibility of a nurse teaching the pregnant adolescent?
Encouraging her to continue regularly scheduled prenatal care
