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NURS 2863 MATERNITY EXAM 2 GUIDE 2022-
A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: A) weight gain of 1 to 3 lbs. B) quickening. C) fatigue and lethargy. D) bloody show. The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: A) progressive uterine contractions with cervical change. B) lightening. C) rupture of membranes. D) passage of the mucous plug (operculum). On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A) The fetal presenting part is 1 cm above the ischial spines. B) Effacement is 4 cm from completion. C) Dilation is 50% completed. D) The fetus has achieved passage through the ischial spines. In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: A) The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. B) Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C) Having the woman point her toes reduces leg cramps. D) The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. The nurse knows that the second stage of labor, the descent phase, has begun when: A) the amniotic membranes rupture. B) The cervix cannot be felt during a vaginal examination. C) The woman experiences a strong urge to bear down. D) The presenting part is below the ischial spines. Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first
stage of labor is accurate? A) Latent: mild, regular contractions; no dilation; bloody show; duration of 2
D. Elevated white blood cell count E. Oral temperature of 99.8° F F. Respiratory rate of 10 breaths/min A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A. encourage the woman to breathe more slowly. B. help the woman breathe into a paper bag. C. turn the woman on her side. D. administer a sedative. A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A. Encourage her to empty her bladder. B. Decrease her intravenous (IV) rate to a keep vein-open rate. C. Turn the woman to the left lateral position or place a pillow under her hip. D. No action is necessary since a decrease in the woman's blood pressure is expected. A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: A. fentanyl (Sublimaze). B.promethazine (Phenergan). C. butorphanol tartrate (Stadol). D. nalbuphine (Nubain). A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A. counterpressure against the sacrum. B. pant-blow (breaths and puffs) breathing techniques. C. effleurage. D. biofeedback.
Nurses should be aware of the difference experience can make in labor pain, such as: A. sensory pain for nulliparous women often is greater than for multiparous women during early labor. B. affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C. women with a history of substance abuse experience more pain during labor. D. multiparous women have more fatigue from labor and therefore experience more pain. With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: A. either hot or cold applications may provide relief, but they should never be used together in the same treatment. B. acupuncture can be performed by a skilled nurse with just a little training. C. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. D. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations. With regard to systemic analgesics administered during labor, nurses should be aware that: A. systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B. effects on the fetus and newborn can include decreased alertness and delayed sucking. C. IM administration is preferred over IV administration. D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic. After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A. visceral. B. referred. C. somatic. D. afterpain.
contractions. D. Variability averages between 6 to 10 beats/min.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to: A. change the woman's position. B. stop the Pitocin. C. elevate the woman's legs. D. administer oxygen via a tight mask at 8 to 10 L/min. You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? A. Notify nursery nurse of imminent delivery. B. Insert a Foley catheter. C. Start oxytocin (Pitocin). D. Notify the primary health care provider immediately (HCP). When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: A. the examiner's hand should be placed over the fundus before, during, and after contractions. B. the frequency and duration of contractions are measured in seconds for consistency. C. contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. D. the resting tone between contractions is described as either placid or turbulent. A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: A. narcotics. B. barbiturates. C. methamphetamines. D. tranquilizers. The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:
A. encouraging the woman to try various upright positions, including squatting and standing. B. telling the woman to start pushing as soon as her cervix is fully dilated. C. continuing an epidural anesthetic so that pain is reduced and the woman can relax. D. coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction. Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? A. The healthy newborn should be taken to the nursery for a complete assessment. B. After drying, the infant should be given to the mother wrapped in a receiving blanket. C. Encourage skin-to-skin contact of mother and baby. D. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta. Which description of the phases of the second stage of labor is accurate? A. Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes B. Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes C. Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Which test is performed to determine if membranes are ruptured? A. Urine analysis B. Fern test C. Leopold maneuvers D. Artificial Rupture of Membranes (AROM) A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: A. "Don't worry about it. You'll do fine." B. "It's normal to be anxious about labor. Let's discuss what makes you afraid." C. "Labor is scary to think about, but the actual experience isn't." D. "You may have an epidural. You won't feel anything." Vaginal examinations should be performed by the nurse under which
of these circumstances. (Select all that apply.)
For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? A. Fetal heart rate of 116 beats/min B. Cervix dilated 2 cm and 50% effaced C. Score of 8 on the biophysical profile D. One fetal movement noted in 1 hour of assessment by the mother A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? A. Place the woman in the knee-chest position. B. Cover the cord in a sterile towel saturated with warm normal saline. C. Prepare the woman for a cesarean birth. D. Start oxygen by face mask. A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: A. uterine contractions occurring every 8 to 10 minutes B. a fetal heart rate (FHR) of 180 with absence of variability C. the client needing to void D. rupture of the client's amniotic membranes With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: A. the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. B. there are no important maternal (as opposed to fetal) contraindications. C. its most important function is to afford the opportunity to administer antenatal glucocorticoids. D. if the client develops pulmonary edema while on tocolytics, IV fluids should be given. With regard to dysfunctional labor, nurses should be aware that: A. women who are underweight are more at risk. B. women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted. C. hypertonic uterine dysfunction is more common than hypotonic dysfunction. D. abnormal labor patterns are most common in older women.
A nurse providing care to a woman in labor should be aware that cesarean birth: A. is declining in frequency in the United States. B. is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier clients do. C. is performed primarily for the benefit of the fetus. D. can be either elected or refused by women as their absolute legal right. Which statement is most likely to be associated with a breech presentation? A. Least common malpresentation B. Descent is rapid C. Diagnosis by ultrasound only D. High rate of neuromuscular disorders A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.) A. Estriol is 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. E. Fetal heart rate of 150 beats/minute The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.) A. Unstable coronary artery disease B. Previous cesarean birth C. Placenta previa D. Initial blood pressure of 132/ E. History of three spontaneous abortions Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: A. return to pre-pregnant weight is usually achieved by the end of the postpartum period. B. fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb weight loss.
D. lactation will inhibit weight loss since caloric intake must increase to support milk production. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: A. wear a snug, supportive bra. B. allow warm water to soothe the breasts during a shower. C. express milk from breasts occasionally to relieve discomfort. D. place absorbent pads with plastic liners into her bra to absorb leakage. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A. urinary tract infection. B. excessive uterine bleeding. C. a ruptured bladder. D. bladder wall atony. What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." C. "I will not have a menstrual cycle for 6 months after childbirth." D. "My first menstrual cycle will be heavier than normal and then will be light for several months after." With regard to afterbirth pains, nurses should be aware that these pains are: A. caused by mild, continual contractions for the duration of the postpartum period. B. more common in first-time mothers. C. more noticeable in births in which the uterus was overdistended. D. alleviated somewhat when the mother breastfeeds. Postbirth uterine/vaginal discharge, called lochia: A. is similar to a light menstrual period for the first 6 to 12 hours. B. is usually greater after cesarean births. C. will usually decrease with ambulation and breastfeeding. D. should smell like normal menstrual flow unless an infection is present.
Which description of postpartum restoration or healing times is accurate? A. The cervix shortens, becomes firm, and returns to form within a month postpartum. B. Rugae reappear within 3 to 4 weeks. C. Most episiotomies heal within a week. D. Hemorrhoids usually decrease in size within 2 weeks of childbirth. With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: A. kidney function returns to normal a few days after birth. B. diastasis recti abdominis is a common condition that alters the voiding reflex. C. fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. D. with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include: A. little if any change B. leakage of milk at let-down C. swollen, warm, and tender on palpation D. a few blisters and a bruise on each areola E. small amount of clear, yellow fluid expressed After completing a postpartum assessment on woman who delivered 20 hours ago, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A. Temperature 100.0° F B. Pulse 110 beats/min C. Respiratory rate 12 breaths/min D. Blood pressure 125/78 E. Temperature 38° C When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:
A. vaginal or vulvar hematomas.
B. unrepaired lacerations of the vagina or cervix. C. failure of the uterine muscle to contract firmly. D. retained placental fragments. Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth? A. 1 hour B. 30 minutes C. 2 hours D. 4 hours Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: A. bladder distention B. uterine atony C. constipation D. hematoma formation Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? (Select all that apply.) A. Postural hypotension B. Temperature of 100.4° F C. Bradycardia—pulse rate of 55 beats/min D. Pain in left calf with dorsiflexion of left foot E. Lochia rubra with foul odor A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? (Select all that apply.) A. Do not perform Kegel exercises to decrease pelvic floor muscle healing time. B. If breastfeeding, sexual interest may be delayed. C. Fatigue may affect interest in sexual activity. D. Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. E. Water-soluble lubrication may increase comfort. F. The female-on-top position may be more comfortable than other positions.
