PERRY’S MATERNAL CHILD NURSING
CARE ;( LABOR AND BIRTH
COMPLICATIONS) QUESTIONS AND
THEIR EXPECTED REVIEWED
ANSWERS
1. In planning for home care of a woman with preterm
labor, which concern must the nurse address?
a. Nursing assessments will be different from those
done in the hospital setting.
b. Restricted activity and medications will be
necessary to prevent recurrence of preterm labor.
c. Prolonged bed rest may cause negative physiologic
effects.
d. Home health care providers will be necessary.
ANS: C
Prolonged bed rest may cause adverse effects such as
weight loss, loss of appetite, muscle wasting, weakness,
bone demineralization, decreased cardiac output, risk for
thrombophlebitis, alteration in bowel functions, sleep
disturbance, and prolonged after birth recovery. Nursing
assessments will differ somewhat from those performed in
the acute care setting, but this is not the concern that
needs to be addressed. Restricted activity and medication
may prevent preterm labor, but not in all women. In
addition, the plan of care is individualized to meet the
,needs of each woman. Many women will receive home
health nurse visits, but care is individualized for each
woman.
2. The nurse providing care for a woman with preterm
labor who is receiving terbutaline would include which
intervention to identify side effects of the drug?
a. Assessing deep tendon reflexes (DTRs)
b. Assessing for chest discomfort and palpitations
c. Assessing for bradycardia
d. Assessing for hypoglycemia
ANS: B
Terbutaline is a 2-adrenergic agonist that affects the
cardiopulmonary and metabolic systems of the mother.
Signs of cardiopulmonary decompensation would include
chest pain and palpitations. Assessing DTRs would not
address these concerns. 2-Adrenergic agonist drugs
cause tachycardia, not bradycardia. The metabolic effect
leads to hyperglycemia, not hypoglycemia.
3. In evaluating the effectiveness of magnesium
sulfate for the treatment of preterm labor, what finding
would alert the nurse to possible side effects?
a. Urine output of 160 mL in 4 hours
b. Deep tendon reflexes 2+ and no clonus
c. Respiratory rate of 16 breaths/min
d. Serum magnesium level of 10 mg/dL
ANS: D
The therapeutic range for magnesium sulfate
management is 5 to 8 mg/dL. A serum magnesium level of
10 mg/dL could lead to signs and symptoms of
magnesium toxicity, including oliguria and respiratory
distress. Urine output of 160 mL in 4 hours, deep tendon
, reflexes 2+ with no clonus, and respiratory rate of 16
breaths/min are normal findings.
4. A woman in preterm labor at 30 weeks of gestation
receives two 12-mg doses of betamethasone
intramuscularly. The purpose of this pharmacologic
treatment is to:
a. stimulate fetal surfactant production.
b. reduce maternal and fetal tachycardia associated
with ritodrine administration.
c. suppress uterine contractions.
d. maintain adequate maternal respiratory effort and
ventilation during magnesium sulfate therapy.
ANS: A
Antenatal glucocorticoids given as intramuscular injections
to the mother accelerate fetal lung maturity. Inderal would
be given to reduce the effects of ritodrine administration.
Betamethasone has no effect on uterine contractions.
Calcium gluconate would be given to reverse the
respiratory depressive effects of magnesium sulfate
therapy
5. A woman at 26 weeks of gestation is being
assessed to determine whether she is experiencing
preterm labor. What finding indicates that preterm
labor is occurring?
a. Estriol is not 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.
ANS: D
Cervical changes such as shortened endocervical length,
CARE ;( LABOR AND BIRTH
COMPLICATIONS) QUESTIONS AND
THEIR EXPECTED REVIEWED
ANSWERS
1. In planning for home care of a woman with preterm
labor, which concern must the nurse address?
a. Nursing assessments will be different from those
done in the hospital setting.
b. Restricted activity and medications will be
necessary to prevent recurrence of preterm labor.
c. Prolonged bed rest may cause negative physiologic
effects.
d. Home health care providers will be necessary.
ANS: C
Prolonged bed rest may cause adverse effects such as
weight loss, loss of appetite, muscle wasting, weakness,
bone demineralization, decreased cardiac output, risk for
thrombophlebitis, alteration in bowel functions, sleep
disturbance, and prolonged after birth recovery. Nursing
assessments will differ somewhat from those performed in
the acute care setting, but this is not the concern that
needs to be addressed. Restricted activity and medication
may prevent preterm labor, but not in all women. In
addition, the plan of care is individualized to meet the
,needs of each woman. Many women will receive home
health nurse visits, but care is individualized for each
woman.
2. The nurse providing care for a woman with preterm
labor who is receiving terbutaline would include which
intervention to identify side effects of the drug?
a. Assessing deep tendon reflexes (DTRs)
b. Assessing for chest discomfort and palpitations
c. Assessing for bradycardia
d. Assessing for hypoglycemia
ANS: B
Terbutaline is a 2-adrenergic agonist that affects the
cardiopulmonary and metabolic systems of the mother.
Signs of cardiopulmonary decompensation would include
chest pain and palpitations. Assessing DTRs would not
address these concerns. 2-Adrenergic agonist drugs
cause tachycardia, not bradycardia. The metabolic effect
leads to hyperglycemia, not hypoglycemia.
3. In evaluating the effectiveness of magnesium
sulfate for the treatment of preterm labor, what finding
would alert the nurse to possible side effects?
a. Urine output of 160 mL in 4 hours
b. Deep tendon reflexes 2+ and no clonus
c. Respiratory rate of 16 breaths/min
d. Serum magnesium level of 10 mg/dL
ANS: D
The therapeutic range for magnesium sulfate
management is 5 to 8 mg/dL. A serum magnesium level of
10 mg/dL could lead to signs and symptoms of
magnesium toxicity, including oliguria and respiratory
distress. Urine output of 160 mL in 4 hours, deep tendon
, reflexes 2+ with no clonus, and respiratory rate of 16
breaths/min are normal findings.
4. A woman in preterm labor at 30 weeks of gestation
receives two 12-mg doses of betamethasone
intramuscularly. The purpose of this pharmacologic
treatment is to:
a. stimulate fetal surfactant production.
b. reduce maternal and fetal tachycardia associated
with ritodrine administration.
c. suppress uterine contractions.
d. maintain adequate maternal respiratory effort and
ventilation during magnesium sulfate therapy.
ANS: A
Antenatal glucocorticoids given as intramuscular injections
to the mother accelerate fetal lung maturity. Inderal would
be given to reduce the effects of ritodrine administration.
Betamethasone has no effect on uterine contractions.
Calcium gluconate would be given to reverse the
respiratory depressive effects of magnesium sulfate
therapy
5. A woman at 26 weeks of gestation is being
assessed to determine whether she is experiencing
preterm labor. What finding indicates that preterm
labor is occurring?
a. Estriol is not 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.
ANS: D
Cervical changes such as shortened endocervical length,
