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Women's Health Exam # 1 Practice
Questions & Answers 2023 A+
The patient is admitted in early labor. Her support person tells the nurse that the contractions have the following pattern: started 1232, ended 1233; started 1235, ended 1236; started 1239, ended 1240; started 1243, ended 1244. From this information, the nurse determines that the frequency of the contractions is? A. every 3 to 4 minutes. B. every 2 to 3 minutes. C. lasting a minute. D. unable to be determined with this information. - ANS-A. every 3 to 4 minutes. The frequency of a contraction is measured from the beginning of one contraction until the beginning of the next contraction. The contractions started at 1232, 1235, 1239, and
- This would put the contractions every 3 to 4 minutes. The duration of the contractions is from the beginning of a contraction until the end of the same contraction. The duration for this pattern would be 1 minute. Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, ?2-1. Which one of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines. B. Effacement is 4 cm from completion. C. Dilation is 50% completed. D. Fetus has passed through the ischial spines. - ANS-A. Fetal presenting part is 1 cm above the ischial spines. A station of ?2-1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of 0 would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged. Passage through the ischial spines with internal rotation would be indicated by a plus station, such as +1. Progress of effacement is referred to by percentages, with 100% indicating full effacement, and dilation by centimeters (cm), with 10 cm indicating full dilation. The midwife records that the patient's cervix is "100%, 5 cm." The nurse understands that the patient's cervix is A. completely dilated and effaced. B. completely dilated and half-effaced. C. completely effaced and half-dilated. D. half-dilated and half-effaced. - ANS-C. completely effaced and half-dilated.
Effacement is measured in percentages. The fully thinned cervix is 100% effaced. The dilation is measured in centimeters; dilation goes from closed to 10 cm. This patient is completely effaced and halfway dilated. To obtain an accurate blood pressure of a woman in labor, the nurse should assess the blood pressure A. between contractions, with the woman lying on her side. B. between contractions, with the woman lying on her back. C. with a contraction while the woman is lying on her side. D. with a contraction while the woman is lying on her back. - ANS-A. between contractions, with the woman lying on her side. During uterine contractions, blood flow to the placenta gradually decreases, causing a relative increase in the woman's blood volume. This temporary change increases her blood pressure slightly. If the woman lies on her back, the weight of the fetus, placenta, and fluid may decrease blood flow, causing supine hypotension. Therefore her blood pressure is more accurate when taken between contractions, with her lying on her side. During active labor, the woman complains about tingling in her hands. The nurse's next action should be to A. help the woman slow down her breathing and breathe into her cupped hands. B. assess vital signs for changes. C. check cervical dilation. D. change the woman's position. - ANS-A. help the woman slow down her breathing and breathe into her cupped hands. Hyperventilation may occur during active labor as the woman breathes rapidly. She may feel tingling in her hands and feet and dizziness. By having the woman slow her breathing and breathe into a paper bag or her cupped hands, her carbon dioxide levels will return to normal and relieve the symptoms. During contractions the fetus has mechanisms in place to protect it from the decrease in blood flow. Those mechanisms include: A. fetal hemoglobin levels that are more resistant to oxygen. Incorrect B. lower hemoglobin and hematocrit levels. C. a high cardiac output level. D. a higher respiratory level. - ANS-C. a high cardiac output level. To prepare for labor, the fetus develops hemoglobin levels that readily take on oxygen and release carbon dioxide. The fetal hemoglobin and hematocrit levels are higher to have more oxygen-carrying capacity. The fetus has a higher cardiac output level. The fetus does not breathe yet, so
Lightening occurs toward the end of the pregnancy as the fetus descends toward the pelvic inlet. When this occurs, the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. The nurse should tell a primigravida that the definitive sign indicating labor has begun is A. progressive uterine contractions. B. lightening. C. rupture of membranes. D. passage of the mucus plug. - ANS-A. progressive uterine contractions. Regular, progressive uterine contractions that increase in intensity and frequency are a sign of true labor. Responses b and d are premonitory signs indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Which one of the following characteristics is associated with false labor contractions? A. Painless B. Decrease in intensity with ambulation C. Regular pattern of frequency is established D. Progressive in terms of intensity and duration - ANS-B. Decrease in intensity with ambulation False labor contractions decrease with activity, but true labor contractions are enhanced or stimulated with activity such as ambulation. False labor contractions are painful. Responses c and d are characteristics of true labor contractions, which increase in intensity with activities such as ambulation. As the nurse is admitting a woman in labor, she notices that the woman is happy and excited that she is in labor. The contractions are 5 minutes apart, lasting 30 to 35 seconds. The nurse can anticipate that the patient is in which phase of labor? A. Second B. Latent C. Active D. Transition - ANS-B. Latent During the latent phase of the first stage of labor, the woman is usually sociable, excited, and cooperative. The contractions are about 5 minutes apart. The midwife has just examined a labor patient and states that she is 10 cm dilated. The nurse is aware that this patient is in which stage of labor? A. First B. Second C. Third D. Fourth - ANS-B. Second The second stage begins with complete dilation (10 cm) and ends with the birth of the baby.
After birth, the woman complains of chills. The first intervention by the nurse should be to A. monitor the maternal temperature. B. monitor the maternal blood pressure. C. place a warm blanket on the woman. D. explain to the woman this is caused by the excitement of birth and will stop in about 30 minutes. - ANS-C. place a warm blanket on the woman. Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket may help shorten the chill. 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 which one of the following? A. Weight gain of 1 to 3 lb B. Quickening C. Fatigue and lethargy D. Bloody show - ANS-D. Bloody show Premonitory signs of labor (prodromal labor) include weight loss of 1 to 3 lb, a burst of energy or the nesting instinct, and passage of the mucus plug (also termed pink or bloody show) as the cervix ripens. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks' gestation. Which one(s) of the following actions should be included in nursing care during labor? (Select all that apply.) A. Offer ice chips in small amounts to relieve a dry mouth. B. Monitor for a full bladder because the woman may have a decreased sensation of the urge to void. C. Keep the woman in a side-lying position to prevent supine hypotension. D. Offer small bland meals if the woman is in early labor to help maintain proper blood sugar levels. E. Monitor the fetal heart rate for changes from normal. - ANS-A. Offer ice chips in small amounts to relieve a dry mouth. B. Monitor for a full bladder because the woman may have a decreased sensation of the urge to void. C. Keep the woman in a side-lying position to prevent supine hypotension. E. Monitor the fetal heart rate for changes from normal Oral intake of clear liquids such as ice chips, juices, and popsicles is appropriate in low risk laboring women; solid foods should be avoided. A full bladder can inhibit fetal descent because it occupies space in the pelvis. Bladder status should be evaluated throughout labor for distention. Alterations in the rate and rhythm of the fetal heart may result from normal labor effects or suggest fetal intolerance to the stress of labor and should be monitored. Supine hypotension may occur during labor if the woman lies on
technique for relaxation when the woman imagines specific scenes that are relaxing. Distraction can be used in the early phase of labor. The woman concentrates on something else, such as playing cards or watching a favorite movie During the latent phase of labor, the nurse suggests that the woman play cards with her husband. The nurse is aware that this will help the woman deal with the pain of contractions. The effectiveness of this technique is explained by A. cutaneous stimulation. B. the gate control theory. C. thermal stimulation. D. hydrotherapy. - ANS-B. the gate control theory. In the gate control theory of pain, the use of visual and auditory stimulation techniques such as playing cards can affect the perception of stimuli as painful. Diversional activities in early labor and focal points or breathing techniques later in labor are examples of the gate control theory of pain. Other examples of gate control theory are cutaneous stimulation using touch to relax muscles, thermal stimulation using warmth to relax muscles, and hydrotherapy using water for relaxation. During the active stage of labor the woman is using a rapid "pant-blow" breathing pattern. She starts to complain of feeling dizzy and has some numbness in her fingers. The nurse's next action should be to A. notify the physician. B. do a vaginal exam to check for the progression of labor. C. have the woman breathe into a paper bag. D. offer pain medication. - ANS-C. have the woman breathe into a paper bag. Hyperventilation is common when breathing techniques are used. It results from rapid deep breathing that causes excessive loss of carbon dioxide and therefore respiratory alkalosis. Having the woman blow into a paper bag or her own cupped hands will increase her carbon dioxide level by having her rebreathe her exhaled air. All of the following women in labor are requesting pain medication. To which one should the nurse administer an opioid analgesic first? A. Primigravida, 2 cm dilated, 50% effaced, grimacing slightly with each contraction B. Gravida 4, 9 cm dilated, 100% effaced, wants to push with each contraction C. Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction D. Primigravida, 1 cm dilated, moans loudly with each contraction, has present history of heroin use - ANS-C. Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction The gravida 2 is well established into the labor and the medication will not slow the contractions. The primigravida who is 2 cm dilated is too early into the labor; the medication may slow or stop her contractions. The gravida 4 is too near birth and the medication may affect the newborn's respiratory effort. The primigravida who is 1 cm dilated has a history of heroin use; further opioid medication is not recommended.
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be A. severe postpartum headache. B. limited perception of bladder fullness. C. increase in respiratory rate. D. hypotension. - ANS-D. hypotension. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure. Headache is not a common side effect because the spinal fluid is not normally disturbed by this anesthetic as it would be with a low spinal anesthetic. Option B is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication. After a planned cesarean section, the woman is being admitted back to the postpartum unit. The nurse notices that the patient is rubbing her nose and eyes continually. Being aware that the woman has been given epidural opioids, the nurse's next action should be to A. offer the woman some medication to relieve the itching. B. notify the anesthesiologist immediately. C. monitor for signs of respiratory depression. D. monitor the patient's temperature - ANS-A. offer the woman some medication to relieve the itching. Pruritus of the face and neck is an annoying side effect that may occur with epidural opioids. Medications may be used to relieve the itching and make the woman more comfortable. Firm sacral pressure is likely to be most helpful in which situation? A. Rapid labor and birth B. Fetal occiput posterior position C. Oxytocin induction of labor D. If analgesics should be avoided - ANS-B. Fetal occiput posterior position A posterior position of the vertex will cause pressure against the sacrum. This pressure increases back pain during and between contractions. Firm sacral pressure may help relieve some of the pressure. A woman must have general anesthesia for a planned cesarean birth because of a previous back surgery. The nurse should therefore expect to administer A. naltrexone (Trexan). B. an oral barbiturate. C. ranitidine (Zantac). D. promethazine (Phenergan). - ANS-C. ranitidine (Zantac). During general anesthesia, there is a risk for maternal aspiration. To prevent lung injury if aspiration occurs, drugs such as ranitidine may be given to raise the gastric pH and make secretions less acidic. Naltrexone is an opioid antagonist, promethazine is used to relieve nausea, and barbiturates are sedating.
Why is a cleansing breath at the beginning and end of contractions important? (Select all that apply.) A. Helps the woman release tension B. Provides oxygen to reduce myometrial hypoxia C. Provides a diversional activity for the woman D. Helps the fetus to release tension - ANS-A. Helps the woman release tension B. Provides oxygen to reduce myometrial hypoxia Each contraction begins and ends with a deep inspiration and expiration known as the cleansing breath. Like a sigh, a cleansing breath helps the woman release tension. It provides oxygen to help reduce myometrial hypoxia, one cause of pain in labor. The cleansing breath also helps the woman clear her mind to focus on relaxing and signals her labor partner that the contraction is beginning or ending. The laboring woman may rub her abdomen during a contraction to counteract discomfort. This is called ______________________. - ANS-Effleurage A primigravida is in the latent phase of labor and is at low risk for complications of labor. She asks the nurse if she may walk for a few minutes. The nurse is aware that this is (is not) possible because A. continuous fetal monitoring is required. B. continuous monitoring of the contractions is necessary at this stage of labor. C. intermittent auscultation of fetal heart rate is appropriate for her. D. there is no need to assess fetal heart rate at this early stage of labor. - ANS-C. intermittent auscultation of fetal heart rate is appropriate for her. Continuous fetal and uterine monitoring is not necessary for the latent phase of labor in women who are at low risk for complications. On review of a fetal monitor tracing, the nurse notes that for several contractions the FHR decelerates as a contraction begins and returns to baseline just before it ends. The nurse should A. describe the finding in the notes. B. reposition the woman onto her side. C. call the physician for instructions. D. administer oxygen at 8 to10 L/minute with a tight face mask. - ANS-A. describe the finding in the notes. An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix. The other responses would be implemented when ominous changes are noted. Which one of the following findings meets the criteria of a Category I FHR pattern? A. The FHR does not change as a result of fetal activity. B. The average baseline rate ranges between 90 and 110 bpm. C. Mild late deceleration patterns occur with some contractions.
D. Variability averages between 6 and 25 bpm. - ANS-D. Variability averages between 6 and 25 bpm. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. The FHR should accelerate with fetal movement. Baseline range for the FHR is from 110 to 160 bpm. Late deceleration patterns are never reassuring. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of oxytocin (Pitocin). The woman is in a side-lying position and her vital signs are stable and 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 oxytocin. C. elevate the woman's legs. D. administer oxygen via a tight mask at 8 to 10 L/minute. - ANS-B. stop the oxytocin. The late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the oxytocin infusion because oxytocin stimulates the uterus to contract. The woman is already in an appropriate position for uteroplacental perfusion. Elevating her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action. During a vaginal exam, the physician stimulates the fetal scalp. The fetal heart rate accelerated from 140 to 155 bpm for about 30 seconds. The nurse should A. record this fetal reaction. B. notify the physician because this reaction is normal. C. assist the woman into a side-lying position. D. administer oxygen at 8 to 10 L/minute - ANS-A. record this fetal reaction. It is normal for the heart rate to elevate 15 bpm for at least 15 seconds with fetal scalp stimulation. The nurse should record the finding. No other intervention is necessary at this time. Firm contractions that occur every 3 minutes and last 100 seconds may reduce fetal oxygen supply because they A. cause fetal bradycardia and reduce oxygen concentration. B. activate the fetal sympathetic nervous system. C. limit the time for oxygen exchange in the placenta. D. suppress the normal variability of the fetal heart. - ANS-C. limit the time for oxygen exchange in the placenta. The resting time between these contractions is about 80 seconds, which reduces the time available for exchange of oxygen and waste products in the placenta. This will reduce the fetal oxygen supply. The other choices can all be results of the decreased oxygen supply. To ensure adequate fetal oxygenation, which one(s) of the following are needed? (Select all that apply.)
F. Prolapsed cord - ANS-A. Maternal hypotension B. Excessive uterine activity C. Maternal hypertension Late decelerations are thought to occur with decreased blood flow through the intervillous space due to maternal, fetal factors, or placental factors resulting in fetal hypoxia. They can be a reflex to transient fetal hypoxia caused by an interruption anywhere along the oxygen pathway such as maternal hypotension. The peak of a uterine contraction produces a temporary cessation of uterine blood flow and oxygen delivery to the intervillous space. Uterine hypertonus may also impact oxygen delivery. Typically, residual oxygen in the intervillous space is adequate enough for the fetus to tolerate these changes. Tachysystole, prolonged contractions, hypertonus, or inadequate relaxation time between contractions may result in FHR changes that are the result of fetal hypoxia. Fever and maternal overhydration would not affect FHR. Prolapsed cord would result in an absence of FHR. Fluctuations in the baseline FHR that cause the printed line to have an irregular rather than a smooth appearance is termed ___________________. - ANS-Variability In caring for a low-risk woman in the active phase of labor, the nurse realizes the assessment of fetal well-being should occur A. every 15 minutes. B. every 30 minutes. C. every 5 minutes. D. every hour. - ANS-B. every 30 minutes For low-risk women, the nurse should evaluate the fetal monitoring strip or assessment fetal well-being at least every 30 minutes during the active phase of labor and every 15 minutes during the second stage. For the high-risk woman, monitoring should occur every 15 minutes during the active phase and every 5 minutes during the second stage. The nurse is preparing to auscultate the fetal heart rate using a Doppler transducer. When performing the Leopold maneuver, the nurse felt the buttocks near the fundus and the back along the left side of the mother. The best position for the Doppler would be in the mother's A. left upper quadrant. B. left lower quadrant. C. right upper quadrant. D. right lower quadrant. - ANS-B. left lower quadrant. The fetal heart is best heard through the fetus's upper back. Because this fetus is in a cephalic position, with the back toward the mother's left side, the Doppler should be placed in the left lower quadrant of the mother's abdomen. A primigravida is admitted in early labor. The nurse notices on the prenatal record that the position of the fetus is left occiput posterior. Because of this information, the nurse can anticipate A. a cesarean section. B. a short labor and birth process.
C. increased back pain with labor.. D. a short labor with a prolonged birth process - ANS-C. increased back pain with labor. When the fetus is in the posterior position, the labor may be longer and more uncomfortable. Back discomfort increases with contractions and will continue between contractions. The fetus may not be able to deliver until it rotates into the anterior position. On admission to the labor suite, a woman begins to cry out loudly, "Lord help me, I am going to die." She repeats this phrase loudly with each contraction. The nurse's best response would be to A. explain to the woman that she is disturbing other patients. B. praise her between contractions when she is quiet. C. understand that this may be a cultural mannerism and accept her individual response to labor. D. understand that this may be a cultural mannerism and do patient teaching to help her understand other ways of expressing her fear and pain. - ANS-C. understand that this may be a cultural mannerism and accept her individual response to labor. Women should be encouraged to express themselves in any way they find comforting. The cultural diversity of their expressions must be respected. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Belittling her, praising her falsely, or trying to show her a "better way" of dealing with the pain will interfere with the therapeutic relationship and lower the woman's self-esteem. Which one of the following women can the nurse anticipate having difficulty dealing with labor pain? A. Primigravida who has attended childbirth preparation classes B. A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. C. A woman having her sixth child and who has not attended any prenatal teaching classes D. Primigravida who has her mother as her birth support person. The mother is encouraging her with every contraction. - ANS-B. A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. Previous experiences with pain can alter a woman's perception of labor pain. The woman with a prolonged labor and posterior position with the last birth will come to this labor anxious about the outcome and amount of pain. Preparation for labor and previous positive experiences will help the woman tolerate the pain. A support person who has been through the process and is encouraging can also assist the woman in a positive way. A 39-week primigravida calls the birthing center and tells the nurse she has contractions that are 10 to 15 minutes apart and had a small gush of fluid about 1 hour ago. The nurse should tell her to A. wait until the contractions are about 5 minutes apart and come to the center. B. come to the birthing center now. C. come to the birthing center in about an hour if she lives farther than 1 hour away.
has bluish coloration in the feet and hands. The proper Apgar score for this newborn should be A. 7. B. 8. C. 9. D. 10. - ANS-B. 8. The heart rate less than 100 bpm gets a score of 1, a lusty cry will give a score of 2 for both respiratory effort and reflex response, the flexed posture and vigorous movements give a score of 2, and the bluish coloration of the hands and feet will give a score of 1. Which one of the following findings during the fourth stage would require immediate interventions by the nurse? A. Fundus firm and at midline B. Fundus firm, deviated to the right, with slight distention over the symphysis pubis C. Blood pressure and pulse slightly lower than reading during second stage of labor D. Lochia is bright red, with a few small clots - ANS-B. Fundus firm, deviated to the right, with slight distention over the symphysis pubis Even though the fundus is firm, it is not midline and the bladder is filling. A full bladder will interfere with contraction of the uterus and lead to increased bleeding. The rest of the answer choices are within normal limits for this stage. Which one of the following measures will help prevent complications from an episiotomy? A. Pain medication every 3 to 4 hours as needed B. Cold applications after birth C. Warm applications after birth D. Early ambulation - ANS-B. Cold applications after birth Cold applications for the first 12 hours after birth may help prevent hematomas and edema. Pain medication helps treat, not prevent, the complication of pain. Early ambulation helps prevent other complications. Warm applications are contraindicated after birth; they may be used after 12 hours. Misoprostol (Cytotec), 50 mcg, has been ordered for a woman to assist with the ripening of the cervix. The nurse's action should be to A. administer the medication vaginally. B. administer the medication orally. C. question the dosage amount. D. monitor for contractions before administering the medication. - ANS-C. question the dosage amount The normal dose of misoprostol for cervical ripening is 25 mcg. A 50-mcg dose is associated with hypertonic contractions. During the labor process, the patient's membranes rupture. Select all the assessments that are necessary for the nurse to carry out at this time. (Select all that apply.) A. Color of amniotic fluid B. Odor of amniotic fluid
C. Fetal heart rate D. Cervical dilation E. Cervical effacement F. Time the membranes ruptured - ANS-A. Color of amniotic fluid B. Odor of amniotic fluid C. Fetal heart rate F. Time the membranes ruptured The time of rupture of membranes, fetal heart rate, color, odor, and quantity of the amniotic fluid are noted and charted. An intravenous access is started in most labor patients because of which one(s) of the following? (Select all that apply.) A. To have quick access if drugs are needed B. To provide fluids to prevent dehydration C. In case an epidural block is administered D. To provide a route for pain medications for the 48-hour postpartum period - ANS-A. To have quick access if drugs are needed B. To provide fluids to prevent dehydration C. In case an epidural block is administered An IV line provides quick access if fluids or medications are needed. Continuous fluid infusion prevents and reduces dehydration and is necessary if epidural analgesia is used. By 48 hours postpartum, mothers are expected to be on oral pain medication. Labor pain management may include which one(s) of the following interventions? (Select all that apply.) A. Cool, damp washcloths on the face and neck B. Decreasing bright lights in the room C. Keeping the woman clean and dry D. Administering pain medication as ordered E. Offering simple snacks every 2 hours - ANS-A. Cool, damp washcloths on the face and neck B. Decreasing bright lights in the room C. Keeping the woman clean and dry D. Administering pain medication as ordered Providing comfort measures are important during labor. A laboring woman may have clear liquids by mouth but no solid food during active labor. Which one(s) of the following are important points when teaching a patient the proper method for pushing during the second stage of labor? (Select all that apply.) A. Begin and end by taking a deep breath and exhaling. B. Push for 4 to 6 seconds at a time. C. Take a deep breath and then push while holding her breath. D. Push at least five or six times with each contraction. - ANS-A. Begin and end by taking a deep breath and exhaling. B. Push for 4 to 6 seconds at a time.
When pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput of the fetal head, it is termed the _______________. - ANS-Ritgen maneuver A vaginal birth after cesarean is often abbreviated __________. - ANS-VBAC Immediately following an amniotomy to observe for complications, the nurse must assess the A. fetal heart rate. B. maternal blood pressure. C. maternal pulse. D. fetal heart rate variability. - ANS-A. fetal heart rate. One complication of an amniotomy is prolapse of the umbilical cord. Cord compression can be diagnosed by observing for variable decelerations or a decrease in the fetal heart rate. Maternal blood pressure, pulse, and fetal variability are all necessary to assess, but are not the immediate concerns. A laboring woman just had an amniotomy performed to augment labor. The nurse is aware that the assessment times for which vital signs will be altered? A. Maternal blood pressure B. Maternal pulse C. Maternal temperature D. Maternal respiration - ANS-C. Maternal temperature With interruption of the membrane barrier, vaginal organisms have free access to the uterine cavity and may cause chorioamnionitis. Assessing the maternal temperature every 2 to 4 hours will be necessary to monitor for signs of infection. D. When admitting a patient for induction of labor, the nurse will question the procedure if which one of the following observations is on the patient's prenatal record? A. Spontaneous rupture of membranes 24 hours ago, with no labor B. 42-week gestation C. Placenta previa. D. Maternal heart disease that is worsening - ANS-C. Placenta previa An induction of labor would be contraindicated in a woman with placenta previa. The labor would most likely result in hemorrhaging. Options a, b, and d are all indications for induction. A woman is receiving oxytocin for labor induction. The nurse notices the woman is having contractions every 2 minutes lasting for 100 seconds. The fetal heart rate is 120 to 130 bpm, with moderate variability. The nurse's next action should be to A. continue to monitor. B. notify the physician. C. turn off the oxytocin. D. turn the oxytocin up to a stronger level - ANS-C. turn off the oxytocin.
The uterine resting tone should have at least 30 seconds between contractions. This woman has a resting time of 20 seconds. The fetal heart rate and variability show no compromise at this time; however, hypertonic contractions can lead to decreased fetal oxygenation. The physician may need to be notified, but after corrective actions have been taken. While caring for a woman who is 10 cm dilated, is pushing, but is fatigued and her pushing efforts are ineffective, the nurse notices that the fetal heart rate has dropped to 85 bpm. The station is +3. The nurse can anticipate A. a cesarean section. B. a low operative vaginal birth. C. a midpelvis operative vaginal birth. D. no change in the birth plan. - ANS-B. a low operative vaginal birth. Because of the drop in the fetal heart rate, the fetus should be delivered quickly. Since the woman is fatigued and no longer pushing effectively, assistance is needed. The head is at +3 station, so a low operative vaginal birth is quicker than preparing the woman for a cesarean section. The fetal head is too low for a midpelvis operative vaginal birth. A 39-week-gestation gravida 1 is 6 cm dilated. Membranes are intact. The labor contractions have decreased in intensity, and she has not dilated in the past 2 hours. A diagnosis of hypotonic dysfunctional labor has been made. The nurse can anticipate which of the following actions? A. Immediate cesarean section B. Amniotomy C. Narcotic administration D. Having her walk around - ANS-B. Amniotomy Amniotomy may be used to stimulate labor that slows after it is established. the urge to push. The nurse can best assist her by A. allowing the epidural to wear off and then have her push. B. letting her labor down, that is delaying pushing until she feels the reflexive urge to push. C. changing her position to a side-lying. D. preparing her for a forceps birth. - ANS-B. letting her labor down, that is delaying pushing until she feels the reflexive urge to push. Epidural analgesia may cause a loss of sensation, so the woman cannot feel the urge to push. The practice of laboring down, or delayed pushing—encouraging the woman to wait until she feels the reflexive urge to push—has shown a lower incidence of adverse effects than pushing immediately on full cervical dilation. She can later be coached to push with each contraction and feedback given on the effectiveness of the pushing. During birth, shoulder dystocia was diagnosed. After the birth and the newborn has been stabilized, it is important for the nurse to assess the newborn for A. hip dysplasia. B. lung excursion.
