Maternity C
A client comes to the hospital in labor. The membranes rupture at 0410. Which action does
the nurse take FIRST?
A. Identifies the amniotic fluid by performing a nitrazine tape test.
B. Contacts a health care provider and prepares for immediate delivery.
C. Documents admission and notes the time of rupture of membranes.
D. Observes the amniotic fluid for any signs of infection or meconium. - ANS-D. Observes
the amniotic fluid for any signs of infection or meconium.
Explanation: It is important to note the color, amount, and odor of the amniotic fluid. The fluid
should be clear and odorless, and may contain white specks (vernix caseosa) and fetal hair.
A yellow-green tinged amniotic fluid may indicate infection or fetal passage of meconium.
Which could possibly have life-threatening complications to the fetus that may require
emergency delivery.
A. The client is in active labor, a nitrazine tape test is not needed at this stage. A nitrazine
tape test would be performed if the client was unsure of whether it was urine incontinence or
ruptured membranes.
B. This is expected during labor, the nurse would not need to prepare for immediate delivery.
The health care provider would need to be told that labor is progressing, however this is not
an emergent notification.
C. The nurse should not and document admission and time of rupture, but it is most
important to assure fetal well-being.
\A client is admitted to the hospital and is scheduled to have a modified radical mastectomy.
The client asks the nurse about the surgical procedure. Which explanation does the nurse
give?
A. "Only the tissue is removed, leaving all the muscles and lymph nodes."
B. "The breast, axillary nodes, and superior apical nodes are removed, but the muscles are
preserved."
C. ""The breast, axillary nodes, and the major and minor pectoral muscles are preserved."
D. "The sternum will be split and the lymph nodes will be dissected from the mediastinum." -
ANS-B. "The breast, axillary nodes, and superior apical nodes are removed, but the muscles
are preserved."
,Explanation: In a modified radical mastectomy, the breast, axillary nodes, and superior apical
nodes are removed, but the major and minor pectoral muscles are preserved.
A. A total (simple) mastectomy is removal of the entire breast with the lymph nodes left
intact.
C. This describes a lumpectomy.
D. This is not a procedure for breast cancer.
\A client is pregnant for the third time. The client has one living child and has had one
abortion. Which description does the nurse record?
A. Gravida III, para II.
B. Gravida II, para II.
C. Gravida III, para I.
D. Gravida II, para III. - ANS-C. Gravida III, para I.
Explanation: The client is experiencing the third pregnancy (gravida III), but in only one
pregnancy did the fetus reach the age of viability (para I). Should the client carry this fetus to
term and deliver the baby live, it will be Gravida III, para II.
A. Gravida denotes the number of pregnancies, para describes live births. As the client has
only had one live birth, para is described incorrectly.
B. Gravida is recoded wrong in this case, as the client has been pregnant three times.
D. Gravida and para are both expressed wrongs this is incorrect.
\A client receives magnesium sulfate intravenously for treatment of preeclampsia. The
client's assessment reveals: BP 110/70 mm Hg, P 98 beats/minute, R 11 breaths/minute,
hyporeflexia, anda urine output of 20 mL/hr. Which analysis by the nurse is BEST?
A. Maternal toxicity has occurred.
B. An additional dose of magnesium sulfate s needed.
C. Desired systemic results have been reached.
D. Drug therapeutic levels have been attained. - ANS-A. Maternal toxicity has occurred.
Explanation: Toxic levels of magnesium sulfate have been reached when respirations are
fewer than 12/min, urine output is less than 25 mL/hr, or reflexes are slowed or absent.
Magnesium balance is crucial to neuromuscular function with a normal range of 1.5 to 2.5
mEq/L (0.75 to 1.25 mmol/L). Hypermagnesemia occurs when levels are greater than 2.5
mEq/L (1.25 mmol/L). Symptoms include hypotension, facial flushing, muscle weakness,
, absent deep tendon reflexes, paralysis, and shallow respirations. Causes include acute
kidney injury and excessive magnesium administration. Treatment includes discontinuing
oral and intravenous (IV) magnesium, supporting ventilation, administering IV calcium
gluconate, and hemodialysis if needed. Nursing considerations include monitoring reflexes,
teaching about over-the-counter drugs containing magnesium, monitoring cardiac rhythm,
and having calcium preparations available to antagonize cardiac depression.
B. Another dose of the medication in this situation could cause cardiac arrest, total paralysis,
or death.
C. Desired results are increased urinary output and the preventions of convulsions. The
client's data indicates that toxic levels of magnesium sulfate have been reached.
D. This data does not support the fact that therapeutic levels have been attained, but rather
toxic levels have been reached.
\By the fifth month of pregnancy, a 32-year-old multipara client of average prenatal height
and weight has gained 14 pounds. Which action by the nurse is MOST important?
A. Advise the client too much weight has been gained and the diet should be reevaluated.
B. Advise the client not enough weight has been gained and the diet should be reevaluated.
C. Inform the client the weight gain is appropriate and the present diet should be maintained.
D. Inform the client difficulties may occur later in pregnancy and more frequent visits to the
health care provider are indicated. - ANS-C. Inform the client the weight gain is appropriate
and the present diet should be maintained.
Explanation: A 14-lb weight gain during the first 5 months of pregnancy is appropriate. The
client should gain 2 to 4 lbs during the first trimester and then approximately 1 lb per week
until birth. A 12 to 16 lb weight gain at this point would be appropriate.
A. This weight gain is appropriate. During the first trimester it is appropriate to gain 2 to 4 lbs.
During the second and third trimester it is appropriate to gain 1 lb/week. Underweight women
will need to gain more, while overweight women will need to gain less.
B. For an average weight and size person, this weight gain is appropriate.
D. There is not an increased number of difficulties during this time in pregnancy. Frequent
health care provider visits are indicated due to increased monitoring for the onset of labor.
\During auscultation of the fetal heart rate (FHR) during labor, the nurse assesses a rate of
59 beats/minute. Which actions does the nurse take FIRST?
A. Turns the client on the right side, opens the IV line, and calls the health care provider.
B. Turns the client on the left side, administers oxygen by nasal cannula, and verifies IV
access.
A client comes to the hospital in labor. The membranes rupture at 0410. Which action does
the nurse take FIRST?
A. Identifies the amniotic fluid by performing a nitrazine tape test.
B. Contacts a health care provider and prepares for immediate delivery.
C. Documents admission and notes the time of rupture of membranes.
D. Observes the amniotic fluid for any signs of infection or meconium. - ANS-D. Observes
the amniotic fluid for any signs of infection or meconium.
Explanation: It is important to note the color, amount, and odor of the amniotic fluid. The fluid
should be clear and odorless, and may contain white specks (vernix caseosa) and fetal hair.
A yellow-green tinged amniotic fluid may indicate infection or fetal passage of meconium.
Which could possibly have life-threatening complications to the fetus that may require
emergency delivery.
A. The client is in active labor, a nitrazine tape test is not needed at this stage. A nitrazine
tape test would be performed if the client was unsure of whether it was urine incontinence or
ruptured membranes.
B. This is expected during labor, the nurse would not need to prepare for immediate delivery.
The health care provider would need to be told that labor is progressing, however this is not
an emergent notification.
C. The nurse should not and document admission and time of rupture, but it is most
important to assure fetal well-being.
\A client is admitted to the hospital and is scheduled to have a modified radical mastectomy.
The client asks the nurse about the surgical procedure. Which explanation does the nurse
give?
A. "Only the tissue is removed, leaving all the muscles and lymph nodes."
B. "The breast, axillary nodes, and superior apical nodes are removed, but the muscles are
preserved."
C. ""The breast, axillary nodes, and the major and minor pectoral muscles are preserved."
D. "The sternum will be split and the lymph nodes will be dissected from the mediastinum." -
ANS-B. "The breast, axillary nodes, and superior apical nodes are removed, but the muscles
are preserved."
,Explanation: In a modified radical mastectomy, the breast, axillary nodes, and superior apical
nodes are removed, but the major and minor pectoral muscles are preserved.
A. A total (simple) mastectomy is removal of the entire breast with the lymph nodes left
intact.
C. This describes a lumpectomy.
D. This is not a procedure for breast cancer.
\A client is pregnant for the third time. The client has one living child and has had one
abortion. Which description does the nurse record?
A. Gravida III, para II.
B. Gravida II, para II.
C. Gravida III, para I.
D. Gravida II, para III. - ANS-C. Gravida III, para I.
Explanation: The client is experiencing the third pregnancy (gravida III), but in only one
pregnancy did the fetus reach the age of viability (para I). Should the client carry this fetus to
term and deliver the baby live, it will be Gravida III, para II.
A. Gravida denotes the number of pregnancies, para describes live births. As the client has
only had one live birth, para is described incorrectly.
B. Gravida is recoded wrong in this case, as the client has been pregnant three times.
D. Gravida and para are both expressed wrongs this is incorrect.
\A client receives magnesium sulfate intravenously for treatment of preeclampsia. The
client's assessment reveals: BP 110/70 mm Hg, P 98 beats/minute, R 11 breaths/minute,
hyporeflexia, anda urine output of 20 mL/hr. Which analysis by the nurse is BEST?
A. Maternal toxicity has occurred.
B. An additional dose of magnesium sulfate s needed.
C. Desired systemic results have been reached.
D. Drug therapeutic levels have been attained. - ANS-A. Maternal toxicity has occurred.
Explanation: Toxic levels of magnesium sulfate have been reached when respirations are
fewer than 12/min, urine output is less than 25 mL/hr, or reflexes are slowed or absent.
Magnesium balance is crucial to neuromuscular function with a normal range of 1.5 to 2.5
mEq/L (0.75 to 1.25 mmol/L). Hypermagnesemia occurs when levels are greater than 2.5
mEq/L (1.25 mmol/L). Symptoms include hypotension, facial flushing, muscle weakness,
, absent deep tendon reflexes, paralysis, and shallow respirations. Causes include acute
kidney injury and excessive magnesium administration. Treatment includes discontinuing
oral and intravenous (IV) magnesium, supporting ventilation, administering IV calcium
gluconate, and hemodialysis if needed. Nursing considerations include monitoring reflexes,
teaching about over-the-counter drugs containing magnesium, monitoring cardiac rhythm,
and having calcium preparations available to antagonize cardiac depression.
B. Another dose of the medication in this situation could cause cardiac arrest, total paralysis,
or death.
C. Desired results are increased urinary output and the preventions of convulsions. The
client's data indicates that toxic levels of magnesium sulfate have been reached.
D. This data does not support the fact that therapeutic levels have been attained, but rather
toxic levels have been reached.
\By the fifth month of pregnancy, a 32-year-old multipara client of average prenatal height
and weight has gained 14 pounds. Which action by the nurse is MOST important?
A. Advise the client too much weight has been gained and the diet should be reevaluated.
B. Advise the client not enough weight has been gained and the diet should be reevaluated.
C. Inform the client the weight gain is appropriate and the present diet should be maintained.
D. Inform the client difficulties may occur later in pregnancy and more frequent visits to the
health care provider are indicated. - ANS-C. Inform the client the weight gain is appropriate
and the present diet should be maintained.
Explanation: A 14-lb weight gain during the first 5 months of pregnancy is appropriate. The
client should gain 2 to 4 lbs during the first trimester and then approximately 1 lb per week
until birth. A 12 to 16 lb weight gain at this point would be appropriate.
A. This weight gain is appropriate. During the first trimester it is appropriate to gain 2 to 4 lbs.
During the second and third trimester it is appropriate to gain 1 lb/week. Underweight women
will need to gain more, while overweight women will need to gain less.
B. For an average weight and size person, this weight gain is appropriate.
D. There is not an increased number of difficulties during this time in pregnancy. Frequent
health care provider visits are indicated due to increased monitoring for the onset of labor.
\During auscultation of the fetal heart rate (FHR) during labor, the nurse assesses a rate of
59 beats/minute. Which actions does the nurse take FIRST?
A. Turns the client on the right side, opens the IV line, and calls the health care provider.
B. Turns the client on the left side, administers oxygen by nasal cannula, and verifies IV
access.
