NUR 113 Exam II Questions And All
Solved Solutions.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long
axis. The nurse documents this finding as which of the following? - Answer The nurse is assessing fetal
lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is
longitudinal to the maternal long axis, the lie is said to longitudinal. Presentation is the portion of the
fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one
another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
p 426
Lie - Answer Refers to the relationship of the long axis (spine) of the fetus to the long axis of the
mother. (Can be described as longitudinal, transverse, or oblique)
A woman with cardiac disease delivered a seven pound baby by C-Section. Which of the following
interventions should be implemented during the immediate postpartum period? - Answer Rest, stool
softeners, and monitoring tolerance of activity.
A woman who has a cardiac condition is at increased risk in the postpartum period. She needs frequent
assessment and observation for tolerance. She would also be given education to avoid straining activities
such as bowel movements and would be encouraged to have stool softeners and increase fluid and fiber.
Restricting the patient's activity to bed rest could be detrimental to the patient, as could be ambulating
to the bathroom only. There is no reason to limit the visits with the infant
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best
action would be to...? - Answer Assess the rate of flow of the oxytocin infusion.
A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea.
Assessing and slowing the infusion rate will relieve symptoms.
S/S of Rubella - Answer fine raised rash, low grade fever, flu like symptoms
In a woman who measures 13 centimeters from the symphysis pubis to the sacral promontory, what
would you estimate the obstetric conjugate to measure? - Answer 11 cm. The obstetric conjugate
measurement is the smallest diameter of the inlet through which the fetus must pass. This cannot be
measured directly, measure the diagonal conjugate and subtract 1.5 to 2.0 centimeters from the
measurement.
, A client with a high thoracic spinal cord injury has just begun labor. She has an indwelling urinary
catheter. Her blood pressure has skyrocketed to 300/160 mm Hg. Which of the following interventions
should the nurse implement to address this complication? - Answer • Elevate the client's head
• Check the catheter for kinks
• Anticipate the need for an antihypertensive agent
In a woman who has a high spinal cord injury (cervical or high thoracic), observe for autonomic
dysreflexia during pregnancy, labor, and the immediate postpartum period. Extreme symptoms such as
severe hypertension (300/160 mm Hg), throbbing headache, flushing of the skin and profuse diaphoresis
above the level of the spinal lesion, nausea, and bradycardia may occur. Immediate action is necessary to
protect against cerebrovascular accident or intraocular damage. Elevate a woman's head to reduce
cerebral pressure and locate the irritating stimulus (usually a distended bladder or bowel). If bladder
distention is the cause, the woman needs bladder pressure relieved by catheterization if an indwelling
catheter is not in place. If a catheter is in place, check to see why it is not draining, then encourage it to
drain by unkinking or flushing to allow urine to flow freely again. Anticipate the need for an
antihypertensive agent to alleviate the extreme hypertension, although as soon as the source of
irritation is removed, symptoms typically fade quickly. The catheter should not be removed. Performing a
blood glucose test and administering an iron supplement are not indicated in this case, as neither
hyperglycemia nor anemia is evident.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which
of the following patterns would you anticipate seeing on the monitor? - Answer Fetal heart rate
declining late with contractions and remaining depressed.
Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from
recovering immediately following a contraction
Complications of chicken pox - Answer encephalitis (swelling of the brain)
Complications of rubella - Answer deafness
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement
for the same contraction, documenting this as which of the following? - Answer Duration refers to how
long a contraction lasts and is measured from the beginning of the increment to the end of the
decrement for the same contraction. Intensity refers to the strength of the contraction determined by
Solved Solutions.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long
axis. The nurse documents this finding as which of the following? - Answer The nurse is assessing fetal
lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is
longitudinal to the maternal long axis, the lie is said to longitudinal. Presentation is the portion of the
fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one
another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
p 426
Lie - Answer Refers to the relationship of the long axis (spine) of the fetus to the long axis of the
mother. (Can be described as longitudinal, transverse, or oblique)
A woman with cardiac disease delivered a seven pound baby by C-Section. Which of the following
interventions should be implemented during the immediate postpartum period? - Answer Rest, stool
softeners, and monitoring tolerance of activity.
A woman who has a cardiac condition is at increased risk in the postpartum period. She needs frequent
assessment and observation for tolerance. She would also be given education to avoid straining activities
such as bowel movements and would be encouraged to have stool softeners and increase fluid and fiber.
Restricting the patient's activity to bed rest could be detrimental to the patient, as could be ambulating
to the bathroom only. There is no reason to limit the visits with the infant
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best
action would be to...? - Answer Assess the rate of flow of the oxytocin infusion.
A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea.
Assessing and slowing the infusion rate will relieve symptoms.
S/S of Rubella - Answer fine raised rash, low grade fever, flu like symptoms
In a woman who measures 13 centimeters from the symphysis pubis to the sacral promontory, what
would you estimate the obstetric conjugate to measure? - Answer 11 cm. The obstetric conjugate
measurement is the smallest diameter of the inlet through which the fetus must pass. This cannot be
measured directly, measure the diagonal conjugate and subtract 1.5 to 2.0 centimeters from the
measurement.
, A client with a high thoracic spinal cord injury has just begun labor. She has an indwelling urinary
catheter. Her blood pressure has skyrocketed to 300/160 mm Hg. Which of the following interventions
should the nurse implement to address this complication? - Answer • Elevate the client's head
• Check the catheter for kinks
• Anticipate the need for an antihypertensive agent
In a woman who has a high spinal cord injury (cervical or high thoracic), observe for autonomic
dysreflexia during pregnancy, labor, and the immediate postpartum period. Extreme symptoms such as
severe hypertension (300/160 mm Hg), throbbing headache, flushing of the skin and profuse diaphoresis
above the level of the spinal lesion, nausea, and bradycardia may occur. Immediate action is necessary to
protect against cerebrovascular accident or intraocular damage. Elevate a woman's head to reduce
cerebral pressure and locate the irritating stimulus (usually a distended bladder or bowel). If bladder
distention is the cause, the woman needs bladder pressure relieved by catheterization if an indwelling
catheter is not in place. If a catheter is in place, check to see why it is not draining, then encourage it to
drain by unkinking or flushing to allow urine to flow freely again. Anticipate the need for an
antihypertensive agent to alleviate the extreme hypertension, although as soon as the source of
irritation is removed, symptoms typically fade quickly. The catheter should not be removed. Performing a
blood glucose test and administering an iron supplement are not indicated in this case, as neither
hyperglycemia nor anemia is evident.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which
of the following patterns would you anticipate seeing on the monitor? - Answer Fetal heart rate
declining late with contractions and remaining depressed.
Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from
recovering immediately following a contraction
Complications of chicken pox - Answer encephalitis (swelling of the brain)
Complications of rubella - Answer deafness
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement
for the same contraction, documenting this as which of the following? - Answer Duration refers to how
long a contraction lasts and is measured from the beginning of the increment to the end of the
decrement for the same contraction. Intensity refers to the strength of the contraction determined by
