Ch 13 14 Flashcards Preview

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Flashcards in Ch 13 14 Deck (56):
1

Ch 13
1.
A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?
A)
ìI'm feeling contractions mostly in my back.î
B)
ìMy contractions are about 6 minutes apart and regular.î
C)
ìThe contractions slow down when I walk around.î
D)
ìIf I try to talk to my partner during a contraction, I can't.î

The contractions slow down when I walk around.

2

2.
Which of the following would indicate to the nurse that the placenta is separating?
A)
Uterus becomes globular
B)
Fetal head is at vaginal opening
C)
Umbilical cord shortens
D)
Mucous plug is expelled

Uterus becomes globular

3

3.
When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics?
A)
Extent of opening to its widest diameter
B)
Degree of thinning
C)
Passage of the mucous plug
D)
Fetal presenting part

Degree of thinning

4

4.
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following?
A)
Increased energy level with alternating strong and weak contractions
B)
Moderately strong contractions every 4 minutes, lasting about 1 minute
C)
Contractions noted in the front of abdomen that stop when she walks
D)
Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

Moderately strong contractions every 4 minutes, lasting about 1 minute

5

5.
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?
A)
Supine
B)
Lithotomy
C)
Upright
D)
Kneeñchest

upright

6

6.
A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:
A)
Latent phase of the first stage of labor
B)
Active phase of the first stage of labor
C)
Transition phase of the first stage of labor
D)
Pelvic phase of the second stage of labor

Transition phase of the first stage of labor

7

7.
The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth?
A)
Cesarean
B)
Vaginal
C)
Forceps-assisted
D)
Vacuum extraction

cesarean

8

8.
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:
A)
Latent phase of the first stage
B)
Active phase of the first stage
C)
Transition phase of the first stage
D)
Perineal phase of the second stage

Latent phase of the first stage

9

9.
A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted?
A)
Platypelloid
B)
Gynecoid
C)
Android
D)
Anthropoid

Gynecoid

10

10.
A woman telephones her health care provider and reports that her ìwater just broke.î Which suggestion by the nurse would be most appropriate?
A)
ìCall us back when you start having contractions.î
B)
ìCome to the clinic or emergency department for an evaluation.î
C)
ìDrink 3 to 4 glasses of water and lie down.î
D)
ìCome in as soon as you feel the urge to push.î

Come to the clinic or emergency department for an evaluation

11

11.
After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful?
A)
The bony pelvis plays a lesser role during labor than soft tissue.
B)
The pelvic outlet is associated with the true pelvis.
C)
The false pelvis lies below the imaginary linea terminalis.
D)
The false pelvis is the passageway through which the fetus travels.

The pelvic outlet is associated with the true pelvis.

12

12.
A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:
A)
+4
B)
+2
C)
0
D)
-2

-2

13

13.
Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?
A)
Frank
B)
Full
C)
Complete
D)
Footling

frank

14

14.
A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure , cramping and lower back pain. The nurse determines that which of the following has most likely occurred?
A)
Cervical dilation
B)
Lightening
C)
Bloody show
D)
Braxton-Hicks contractions

lightening

15

15.
After teaching a group of students about the factors affecting the labor process, the instructor determines that the teaching was successful when the group identifies which of the following as a component of the true pelvis? (Select all that apply.)
A)
Pelvic inlet
B)
Cervix
C)
Mid pelvis
D)
Pelvic outlet
E)
Vagina
F)
Pelvic floor muscles

pelvic inlet, mid pelvis, pelvic outlet

16

16.
A nurse is documenting fetal lie of a woman in labor. Which term would the nurse most likely use?
A)
Flexion
B)
Extension
C)
Longitudinal
D)
Cephalic

Longitudinal

17

17.
The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which of the following is the presenting part?
A)
Occiput
B)
Face
C)
Buttocks
D)
Shoulder

Buttocks

18

18.
A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which of the following would the nurse most likely include? (Select all that apply.)
A)
Internal rotation
B)
Abduction
C)
Descent
D)
Pronation
E)
Flexion

Internal rotation
Descent
Flexion

19

19.
The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which of the following?
A)
Increment
B)
Acme
C)
Peak
D)
Decrement

Increment

20

20.
A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?
A)
Heart rate increase from 76 bpm to 90 bpm
B)
Blood pressure rise from 110/60 mm Hg to 120/74
C)
White blood cell count of 12,000 cells/mm3
D)
Respiratory rate of 10 breaths /minute

Respiratory rate of 10 breaths /minute

21

21.
When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage?
A)
Regular contractions
B)
Cervical dilation
C)
Fetal movement through the birth canal
D)
Placental separation

Cervical dilation

22

22.
A nurse is caring for several women in labor. The nurse determines that which woman is in the transition phase of labor?
A)
Contractions every 5 minutes, cervical dilation 3 cm
B)
Contractions every 3 minutes, cervical dilation 5 cm
C)
Contractions every 2Ω minutes, cervical dilation 7 cm
D)
Contractions every 1 minute, cervical dilation 9 cm

Contractions every 1 minute, cervical dilation 9 cm

23

23.
A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which of the following would the nurse most likely include when discussing measures to promote coping for a positive labor experience? (Select all that apply.)
A)
Presence of a support partner
B)
View of birth as a stressor
C)
Low anxiety level
D)
Fear of loss of control
E)
Participation in a pregnancy exercise program

Presence of a support partner
Low anxiety level
Participation in a pregnancy exercise program

24

24.
During a follow-up prenatal visit, a pregnant woman asks the nurse, ìHow long do you think I will be in labor?î Which response by the nurse would be most appropriate?
A)
ìIt's difficult to predict how your labor will progress, but we'll be there for you the entire time.î
B)
ìSince this is your first pregnancy, you can estimate it will be about 10 hours.î
C)
ìIt will depend on how big the baby is when you go into labor.î
D)
ìTime isn't important; your health and the baby's health are key.î

It's difficult to predict how your labor will progress, but we'll be there for you the entire time.

25

25.
A nurse is describing how the fetus moves through the birth canal. Which of the following would the nurse identify as being most important in allowing the fetal head to move through the pelvis?
A)
Sutures
B)
Fontanelles
C)
Frontal bones
D)
Biparietal diameter

Sutures

26

26.
Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station?
A)
ñ2
B)
ñ1
C)
0
D)
+1

0

27

Ch 14
1.
A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?
A)
Butorphanol
B)
Fentanyl
C)
Naloxone
D)
Promethazine

Naloxone

28

2.
A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next?
A)
Check the fetal heart rate.
B)
Perform a vaginal exam.
C)
Notify the physician immediately.
D)
Change the linen saver pad.

Check the fetal heart rate.

29

3.
A woman has just entered the second stage of labor. The nurse would focus care on which of the following?
A)
Encouraging the woman to push when she has a strong desire to do so
B)
Alleviating perineal discomfort with the application of ice packs
C)
Palpating the woman's fundus for position and firmness
D)
Completing the identification process of the newborn with the mother

Encouraging the woman to push when she has a strong desire to do so

30

4.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next?
A)
Continue to monitor the FHR because this pattern is benign.
B)
Perform a vaginal exam to assess cervical dilation and effacement.
C)
Stay with the client while reporting the finding to the physician.
D)
Administer oxygen after turning the client on her left side.

Continue to monitor the FHR because this pattern is benign.

31

5.
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
A)
+2 station
B)
0 station
C)
-2 station
D)
Crowning

-2 station

32

6.
The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?
A)
Feel for the fetal buttocks or head while palpating the abdomen.
B)
Feel for the fetal back and limbs as the hands move laterally on the abdomen.
C)
Palpate for the presenting part in the area just above the symphysis pubis.
D)
Determine flexion by pressing downward toward the symphysis pubis.

Feel for the fetal buttocks or head while palpating the abdomen.

33

7.
A client states, ìI think my waters broke! I felt this gush of fluid between my legs.î The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns:
A)
Yellow
B)
Olive green
C)
Pink
D)
Blue

Blue

34

8.
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman's medical record to ensure which of the following as being required?
A)
Intact membranes
B)
Cervical dilation of 2 cm or more
C)
Floating presenting fetal part
D)
A neonatologist to insert the electrode

Cervical dilation of 2 cm or more

35

9.
When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next?
A)
Have the woman change her position.
B)
Administer oxygen.
C)
Notify the health care provider.
D)
Continue to monitor the pattern every 15 minutes.

Notify the health care provider.

36

10.
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?
A)
ìThe warmth and buoyancy of the water has a nice relaxing effect.î
B)
ìI can stay in the bath for as long as I feel comfortable.î
C)
ìMy cervix should be dilated more than 5 cm before I try using this method.î
D)
ìThe temperature of the water should be at least 105º F.î

The temperature of the water should be at least 105º F

37

11.
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following?
A)
Respiratory depression
B)
Urinary retention
C)
Abdominal distention
D)
Hyperreflexia

Respiratory depression

38

12.
When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR?
A)
Over the uterine fundus where contractions are most intense
B)
Above the umbilicus toward the right side of the diaphragm
C)
Between the umbilicus and the symphysis pubis
D)
Between the xiphoid process and umbilicus

Between the umbilicus and the symphysis pubis

39

13.
After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching?
A)
ìThis type of monitoring is the most accurate method for our baby.î
B)
ìUnfortunately, I'm going to have to stay quite still in bed while it is in place.î
C)
ìThis type of monitoring can only be used after my membranes rupture.î
D)
ìYou'll be inserting a special electrode into my baby's scalp.î

Unfortunately, I'm going to have to stay quite still in bed while it is in place.

40

14.
When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?
A)
Every 2 to 4 hours
B)
Every 45 to 60 minutes
C)
Every 15 to 30 minutes
D)
Every 10 to 15 minutes

Every 15 to 30 minutes

41

15.
Which of the following is a priority when caring for a woman during the fourth stage of labor?
A)
Assessing the uterine fundus
B)
Offering fluids as indicated
C)
Encouraging the woman to void
D)
Assisting with perineal care

Assessing the uterine fundus

42

16.
When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?
A)
Intense
B)
Strong
C)
Moderate
D)
Mild

Moderate

43

17.
A nurse palpates a woman's fundus to determine contraction intensity. Which of the following would be most appropriate for the nurse to use for palpation?
A)
Finger pads
B)
Palm of the hand
C)
Finger tips
D)
Back of the hand

Finger pads

44

18.
A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as which of the following?
A)
Normal
B)
Possible infection
C)
Meconium passage
D)
Transient fetal hypoxia

Possible infection

45

19.
After teaching a group of students about fetal heart rate patterns, the instructor determines the need for additional teaching when the students identify which of the following as indicating normal fetal acidñbase status? (Select all that apply.)
A)
Sinusoidal pattern
B)
Recurrent variable decelerations
C)
Fetal bradycardia
D)
Absence of late decelerations
E)
Moderate baseline variability

Sinusoidal pattern
Recurrent variable decelerations
Fetal bradycardia

46

20.
A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which of the following?
A)
Early decelerations
B)
Variable decelerations
C)
Prolonged decelerations
D)
Late decelerations

Variable decelerations

47

21.
A nurse is explaining the use of therapeutic touch as a pain relief measure during labor. Which of the following would the nurse include in the explanation?
A)
ìThis technique focuses on manipulating body tissues.î
B)
ìThe technique requires focusing on a specific stimulus.î
C)
ìThis technique redirects energy fields that lead to pain.î
D)
ìThe technique involves light stroking of the abdomen with breathing.î

This technique redirects energy fields that lead to pain

48

22.
A group of nursing students are reviewing the various medications used for pain relief during labor. The students demonstrate understanding of the information when they identify which agent as the most commonly used opioid?
A)
Butorphanol
B)
Nalbuphine
C)
Fentanyl
D)
Meperidine

Meperidine

49

23.
A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful?
A)
ìWe can get up and walk around after receiving combined spinalñepidural analgesia.î
B)
ìHigher anesthetic doses are needed for patient-controlled epidural analgesia.î
C)
ìA pudendal nerve block is highly effective for pain relief in the first stage of labor.î
D)
ìLocal infiltration using lidocaine is an appropriate method for controlling contraction pain.î

We can get up and walk around after receiving combined spinalñepidural analgesia.

50

24.
A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which of the following would the nurse expect to include as part of the physical assessment? (Select all that apply.)
A)
Current pregnancy history
B)
Fundal height measurement
C)
Support system
D)
Estimated date of birth
E)
Membrane status
F)
Contraction pattern

Fundal height measurement
Membrane status
Contraction pattern

51

25.
A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which of the following would the nurse expect to include when developing a plan of care for this women? (Select all that apply.)
A)
Administration of penicillin G at the onset of labor
B)
Avoidance of scalp electrodes for fetal monitoring
C)
Refraining from obtaining fetal scalp blood for pH testing
D)
Adminstering zidovudine at the onset of labor.
E)
Electing for the use of forceps-assisted delivery

Avoidance of scalp electrodes for fetal monitoring
Refraining from obtaining fetal scalp blood for pH testing
Adminstering zidovudine at the onset of labor.

52

26.
Which position would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? (Select all that apply.)
A)
Walking with partner support
B)
Straddling with forward leaning over a chair
C)
Closed kneeñchest position
D)
Rocking back and forth with foot on chair
E)
Supine with legs raised at a 90-degree angle

Walking with partner support
Straddling with forward leaning over a chair
Rocking back and forth with foot on chair

53

27.
Which of the following would be most appropriate for the nurse to suggest about pushing to a woman in the second stage of labor?
A)
ìLying flat with your head elevated on two pillows makes pushing easier.î
B)
ìChoose whatever method you feel most comfortable with for pushing.î
C)
ì Let me help you decide when it is time to start pushing.î
D)
ìBear down like you're having a bowel movement with every contraction.î

Choose whatever method you feel most comfortable with for pushing.

54

28.
A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which of the following?
A)
Skin
B)
Muscles of perineal body
C)
Anal sphincter
D)
Anterior rectal wall

Muscles of perineal body

55

29.
A nurse is assisting with the delivery of a newborn. The fetal head has just emerged. Which of the following would be done next?
A)
Suctioning of the mouth and nose
B)
Clamping of the umbilical cord
C)
Checking for the cord around the neck
D)
Drying of the newborn

Checking for the cord around the neck

56

30.
A nurse is providing care to a woman during the third stage of labor. Which of the following would alert the nurse that the placenta is separating? (Select all that apply.)
A)
Boggy, soft uterus
B)
Uterus becoming discoid shaped
C)
Sudden gush of dark blood from the vagina
D)
Shortening of the umbilical cord

Sudden gush of dark blood from the vagina