MaternalNewborn chapter 15 test bank QUESTIONS AND ANSWERS 100 VERIFIED A GUARANTEED

Maternal-Newborn chapter 15 test bank QUESTIONS AND ANSWERS 100% VERIFIED A+ GUARANTEED Which comfort measure should the nurse utilize a laboring woman to relax? A: recommend frequent position changes B: palpate her filling bladder every 15 minutes C: offer warm wet cloths to use on the client's face and neck D: keep the room lights lit so the client and her coach can see everything Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient? A: elevated pulse rate B: elevated blood pressure C: firm funds at the midline D: saturation of two perineal pads in 4 hours Which intervention is an essential part of nursing care for a laboring patient? A: helping the woman manage the pain B: eliminating the pain associated with labor C: feeling comfortable with the predictable nature of intrapartal care D: sharing personal experiences regarding labor and birth to decrease her anxiety A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: A: increased fetal movement B: irregular contractions for 1 hour C: a trickle of fluid from the vagina D: thick pink or dark red vaginal mucus Which patient at term should proceed to the hospital or birth center the immediately after labor begins? A: gravida 2, para 1, who lives 10 minutes away B: gravida 1, para 0, who lives 40 minutes away C: gravida 2, para 1, whose first labor lasted 16 hours D: gravida 3, para 2, whose longest previous labor was 4 hours A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5-9 minutes apart, 20-30 seconds in duration, and of mild intensity. Cervical dilation is 1-2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the patient to be: A: discharged home with a sedative B: admitted for extended observation C: admitted and prepared for a cesarean birth D: discharged home to await the onset of true labor The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing interventions is most appropriate at this time? A: inform the mother that the fetal heart rate is normal B: reassess the fetal heart rate in 5 minutes because the rate is too high C: report the fetal heart rate to the physician or nurse-midwife immediately D: suggest to the mother that she is going to have a boy because the heart rate is fast Which clinical finding would be an indication to the nurse that the fetus may be compromised? A: active fetal movements B: fetal heart rate in the 140s C: contractions lasting 90 seconds D: meconium-stained amniotic fluid The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate? A: every 15 minutes B: every 30 minutes C: every 45 minutes D: every 1 hour Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth? A: bloody mucous discharge increases B: the vulva bulges and encircles the fetal head C: the membranes rupture during a contraction D: the fetal head is felt at 0 station during the vaginal examination During labor a vaginal examination should be performed only when necessary because of the risk of: A: infection B: fetal injury C: discomfort D: perineal trauma A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the patient pushes her husband's hand away and shouts, "Don't touch me?" This behavior is most likely: A: a sign of abnormal labor progress B: an indication that she needs analgesia C: normal and related to hyperventilation D: common during the transition phase of labor The nurse thoroughly dries the infant immediately after birth primarily to: A: reduce heat loss from evaporation B: stimulate crying and lung expansion C: increase blood supply to the hands and feet D: remove maternal blood from the skin surface The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? A: request a social service consult for psychosocial support B: observe for other signs that the mother may not be accepting of the infant C: document this evidence of normal early maternal-infant attachment behavior D: determine whether the mother is too fatigues to interact normally with her infant Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours. A: fluid volume deficit (FVD) related to fluid loss during labor and birth process B: fatigue related to length of labor requiring increased energy expenditure C: acute pain related to increased intensity of contractions D: anxiety related to imminent birth process Which of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor? A: length of a second-stage labor is 2 hours B: patient has received an epidural for pain control during the labor process C: patient is using breathing techniques during contractions to maximize pain relief D: patient is receiving parenteral fluids during the course of labor to maintain hydration The nurse assess the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? A: bloody B: clear with bits of vernix caseosa C: green and thick D: yellow and cloudy with foul odor The nurse is preparing to initiate IV access on a patient in the active phase of labor. Which IV cannula is best for this patient? A: 18-gauge B: 20-gauge C: 22-gauge D: 24-gauge While assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider? A: maternal pulse rate of 100 bpm B: maternal blood pressure of 120/70 mm Hg C: persistent fetal bradycardia below 100 bpm D: decreased intensity of uterine contractions The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric provider? A: to determine the status of the membranes B: to determine cervical dilation and effacement C: to determine the best location to assess the fetal heart rate D: to determine whether the fetus is in the posterior position A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include: A: contraction pattern, amount of discomfort, and pregnancy history B: fetal heart rate, maternal vital signs, and the woman's nearness to birth C: last food intake, when labor began, and cultural practices the couple desires D: identification of ruptured membranes, the woman's gravida and para, and access to a support person At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink and the hands and feet are blue. The Apgar score for this infant is: A: 7 B: 8 C: 9 D: 10 If a woman's funds is soft 30 minutes after birth, the nurse's first action should be to: A: massage the fundus B: take the blood pressure C: notify the physician or nurse-midwife D: place the woman in Trendelenburg position A nursing priority during admission of a laboring patient who has not had prenatal care is: A: obtaining admission labs B: identifying labor risk factors C: discussing her birth plan choices D: explaining importance of prenatal care The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record? A: fetal heart rate B: pain level C: test results ensuring that the fluid is not urine D: the patient's understanding of the event For which patient should oxytocin (Pitocin) infusion be discontinued immediately? A: a patient in transition with contractions every 2 minutes lasting 90 seconds each B: a patient in early labor with contractions every 5 minutes lasting 40 seconds each C: a patient in active labor with contractions every 3 minutes lasting 60 seconds each D: a patient in active labor with contractions every 2-3 minutes lasting 70-80 seconds each Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth? A: presence of newborn reflexes B: symmetry of facial movements C: caput and molding of the head D: anterior and posterior fontanels Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) A: place the newborn covered with blankets in the radiant warmer B: dry the infant off with sterile towels C: place stockinette cap on infant's head D: bathe the newborn within 30 minutes of birth E: remove wet linen as needed