Focus On Maternity Test Exam Questions And Answers
Verified 100% Correct
A nonstress test is performed, and the health care provider
documents "accelerations lasting less than 15 seconds
throughout fetal movement." The nurse interprets these findings
as: - ANSWER Nonreactive
A reactive nonstress test is a normal, or negative, result and
indicates a healthy fetus. The result requires two or more fetal
heart rate accelerations of at least 15 beats/min lasting at least 15
seconds from the beginning of the acceleration to the end, in
association with fetal movement, during a 20-minute period. A
nonreactive test is an abnormal test, showing no accelerations or
accelerations of less than 15 beats/min or lasting less than 15
seconds during a 40-minute observation. An inconclusive result is
one that cannot be interpreted because of the poor quality of the
fetal heart rate recording.
A stillborn infant was delivered a few hours ago. After the birth,
the family remains together, holding and touching the baby.
Which statement by the nurse is appropriate? - ANSWER "This
must be hard for you."
Therapeutic communication helps the mother, father, and other
family members express their feelings and emotions. "This must
be hard for you" is a caring and empathetic response, focused on
feelings and encouraging communication. The other options are
nontherapeutic and may devalue the family members' feelings.
A nurse is providing nutritional counseling to pregnant client with
a history of cardiac disease. What does the nurse advise the
client to eat? - ANSWER Apple and whole-grain toast
,The pregnant woman needs a well-balanced diet high in iron and
protein and adequate in calories for weight gain. Iron supplements
that are taken during pregnancy tend to cause constipation.
Constipation causes the client to strain during defecation,
inadvertently performing the Valsalva maneuver, which causes
blood to rush to the heart and overload the cardiac system. The
pregnant woman, then, should increase her intake of fluids and
fiber. An unlimited intake of sodium (pretzels, cheese, nachos)
could cause overload of the circulating blood volume and
contribute to the cardiac condition.
A delivery room nurse is preparing a client for a cesarean
delivery. The client is placed on the delivery room table, and the
nurse positions the client: - ANSWER Supine with a wedge
under the right hip
The pregnant client is positioned so that the uterus is displaced
laterally to prevent compression of the inferior vena cava, which
causes decreased placental perfusion. This is accomplished by
placing a wedge under the hip. Positioning for abdominal surgery
necessitates a supine position. The Trendelenburg position
places pressure from the pregnant uterus on the diaphragm and
lungs, decreasing respiratory capacity and oxygenation. A
semiFowler or prone position is not practical for this type of
abdominal surgery.
A nurse is preparing to perform the Leopold maneuvers on a
pregnant client. The nurse should first: - ANSWER Ask the client
to empty her bladder
In preparation for the Leopold maneuvers, the nurse first asks the
woman to empty her bladder, which will contribute to the woman's
,comfort during the examination. Next the nurse positions the
client supine with a wedge placed under the hip to displace the
uterus. Often the Leopold maneuvers are performed to aid the
examiner in locating the fetal heart tones. Counting the fetal heart
rate is not associated with Leopold maneuvers.
A nurse is assessing the lochia of a client who delivered a viable
newborn 1 hour ago. Which type of lochia would the nurse expect
to note at this time? - ANSWER Dark-red lochia rubra
When the perineum is assessed, the lochia is checked for
amount, color, and the presence of clots. The color of the lochia
during the fourth stage of labor (1 to 4 hours after birth) is dark
red (rubra). This is an expected occurrence until the third day
after delivery. Then, from days 4 through 10, the discharge is
brownish pink (serosa). Alba is a white discharge that occurs on
days 11 to 14.
A nurse provides instructions to a breastfeeding mother who is
experiencing breast engorgement about measures for treating the
problem. The nurse tells the mother to: - ANSWER Gently
massage the breasts during breastfeeding to help empty the
breasts
Gently massaging the breasts during breast feeding will help
empty the breasts. The mother should not avoid breastfeeding
during the night; instead, she should breastfeed every 2 hours or
pump the breasts. The nurse instructs the woman to apply ice
packs, not heat packs, to the breasts between feedings to reduce
swelling. It may be helpful for the mother to stand in a warm
shower just before feeding to foster relaxation and letdown.
When, during the normal postpartum course, would the nurse
, expect to note the fundal assessment shown in the figure? -
ANSWER Immediately after delivery
Immediately after delivery, the uterine fundus should be at the
level of the umbilicus or one to three fingerbreadths below it and
in the midline of the abdomen. Location of the fundus above the
umbilicus may indicate the presence of blood clots in the uterus
that need to be expelled by means of fundal massage. A fundus
that is not located in the midline may indicate a full bladder. The
fundus descends 1 or 2 cm every 24 hours, so it should be
located farther below the umbilicus with every succeeding
postpartum day.
A nurse is monitoring a client in labor for signs of intrauterine
infection. Which sign, indicative of infection, would prompt the
nurse to contact the health care provider? - ANSWER
Strongsmelling amniotic fluid
Signs associated with intrauterine infection includes fetal
tachycardia (rising baseline or faster than 160 beats/min, a
maternal fever (38° C or 100.4° F), foul or strong-smelling
amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal
heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal.
Maternal fatigue normally occurs during labor.
A nurse in the labor room is preparing to care for a client with
hypertonic uterine dysfunction. The nurse is told that the client is
experiencing uncoordinated contractions that are erratic in their
frequency, duration, and intensity. What is the priority nursing
intervention in the care of this client? - ANSWER Providing pain
relief
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A nonstress test is performed, and the health care provider
documents "accelerations lasting less than 15 seconds
throughout fetal movement." The nurse interprets these findings
as: - ANSWER Nonreactive
A reactive nonstress test is a normal, or negative, result and
indicates a healthy fetus. The result requires two or more fetal
heart rate accelerations of at least 15 beats/min lasting at least 15
seconds from the beginning of the acceleration to the end, in
association with fetal movement, during a 20-minute period. A
nonreactive test is an abnormal test, showing no accelerations or
accelerations of less than 15 beats/min or lasting less than 15
seconds during a 40-minute observation. An inconclusive result is
one that cannot be interpreted because of the poor quality of the
fetal heart rate recording.
A stillborn infant was delivered a few hours ago. After the birth,
the family remains together, holding and touching the baby.
Which statement by the nurse is appropriate? - ANSWER "This
must be hard for you."
Therapeutic communication helps the mother, father, and other
family members express their feelings and emotions. "This must
be hard for you" is a caring and empathetic response, focused on
feelings and encouraging communication. The other options are
nontherapeutic and may devalue the family members' feelings.
A nurse is providing nutritional counseling to pregnant client with
a history of cardiac disease. What does the nurse advise the
client to eat? - ANSWER Apple and whole-grain toast
,The pregnant woman needs a well-balanced diet high in iron and
protein and adequate in calories for weight gain. Iron supplements
that are taken during pregnancy tend to cause constipation.
Constipation causes the client to strain during defecation,
inadvertently performing the Valsalva maneuver, which causes
blood to rush to the heart and overload the cardiac system. The
pregnant woman, then, should increase her intake of fluids and
fiber. An unlimited intake of sodium (pretzels, cheese, nachos)
could cause overload of the circulating blood volume and
contribute to the cardiac condition.
A delivery room nurse is preparing a client for a cesarean
delivery. The client is placed on the delivery room table, and the
nurse positions the client: - ANSWER Supine with a wedge
under the right hip
The pregnant client is positioned so that the uterus is displaced
laterally to prevent compression of the inferior vena cava, which
causes decreased placental perfusion. This is accomplished by
placing a wedge under the hip. Positioning for abdominal surgery
necessitates a supine position. The Trendelenburg position
places pressure from the pregnant uterus on the diaphragm and
lungs, decreasing respiratory capacity and oxygenation. A
semiFowler or prone position is not practical for this type of
abdominal surgery.
A nurse is preparing to perform the Leopold maneuvers on a
pregnant client. The nurse should first: - ANSWER Ask the client
to empty her bladder
In preparation for the Leopold maneuvers, the nurse first asks the
woman to empty her bladder, which will contribute to the woman's
,comfort during the examination. Next the nurse positions the
client supine with a wedge placed under the hip to displace the
uterus. Often the Leopold maneuvers are performed to aid the
examiner in locating the fetal heart tones. Counting the fetal heart
rate is not associated with Leopold maneuvers.
A nurse is assessing the lochia of a client who delivered a viable
newborn 1 hour ago. Which type of lochia would the nurse expect
to note at this time? - ANSWER Dark-red lochia rubra
When the perineum is assessed, the lochia is checked for
amount, color, and the presence of clots. The color of the lochia
during the fourth stage of labor (1 to 4 hours after birth) is dark
red (rubra). This is an expected occurrence until the third day
after delivery. Then, from days 4 through 10, the discharge is
brownish pink (serosa). Alba is a white discharge that occurs on
days 11 to 14.
A nurse provides instructions to a breastfeeding mother who is
experiencing breast engorgement about measures for treating the
problem. The nurse tells the mother to: - ANSWER Gently
massage the breasts during breastfeeding to help empty the
breasts
Gently massaging the breasts during breast feeding will help
empty the breasts. The mother should not avoid breastfeeding
during the night; instead, she should breastfeed every 2 hours or
pump the breasts. The nurse instructs the woman to apply ice
packs, not heat packs, to the breasts between feedings to reduce
swelling. It may be helpful for the mother to stand in a warm
shower just before feeding to foster relaxation and letdown.
When, during the normal postpartum course, would the nurse
, expect to note the fundal assessment shown in the figure? -
ANSWER Immediately after delivery
Immediately after delivery, the uterine fundus should be at the
level of the umbilicus or one to three fingerbreadths below it and
in the midline of the abdomen. Location of the fundus above the
umbilicus may indicate the presence of blood clots in the uterus
that need to be expelled by means of fundal massage. A fundus
that is not located in the midline may indicate a full bladder. The
fundus descends 1 or 2 cm every 24 hours, so it should be
located farther below the umbilicus with every succeeding
postpartum day.
A nurse is monitoring a client in labor for signs of intrauterine
infection. Which sign, indicative of infection, would prompt the
nurse to contact the health care provider? - ANSWER
Strongsmelling amniotic fluid
Signs associated with intrauterine infection includes fetal
tachycardia (rising baseline or faster than 160 beats/min, a
maternal fever (38° C or 100.4° F), foul or strong-smelling
amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal
heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal.
Maternal fatigue normally occurs during labor.
A nurse in the labor room is preparing to care for a client with
hypertonic uterine dysfunction. The nurse is told that the client is
experiencing uncoordinated contractions that are erratic in their
frequency, duration, and intensity. What is the priority nursing
intervention in the care of this client? - ANSWER Providing pain
relief
