Maternity Practice Exam – 50 questions. – Flashcards
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During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?
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Have her cup both hands over her nose and mouth while breathing. Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both hands over her mouth and nose so she can rebreathe carbon dioxide.
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A client who delivered by cesarean section 24 hours ago is using a PCA pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
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Impaired bowel motility related to pain medication and immobility.Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.
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A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate?
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"Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) , if the infant is adequately hydrated. Although a weight gain of 30 grams/day is indicative of adequate nutrition, most home scales do not measure this accurately and this suggestion is likely to make the mother very anxious.
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The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
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Two weeks before menstruation. Ovulation occurs 14 days before the first day of the menstrual period . While ovulation can occur in the middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of their menstrual cycle varies.
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The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines the client is dilated 7 cm, is 100% effaced at 0 station, with intact membranes. The monitor indicates the fetal heart rate (FHR) decelerates at the onset of several contractions and returns to baseline before each contraction ends. What action should the nurse take?
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Continue to monitor labor progress. The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record.
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The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
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Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands .
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Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. What is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line in a newborn?
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A cephalhematoma, which is caused by forceps trauma. Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull.
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One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, his hands shake. What intervention should the nurse implement first?
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Obtain a serum glucose level. This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level .
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A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she expected. Her partner is also becoming anxious. The nurse's response should focus on which content?
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Asking the client and her partner if they would like the nurse stay in the room. Offering to remain with the client and her partner (C) offers support without providing false reassurance. The length of labor is not always predictable, but (A and B) do not offer the client the support that is needed at this time. (D) may be reassuring regarding the fetal heart rate, but it does not provide the client the emotional support she needs at this time during the labor process.
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A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy is prescribed. What instruction should the nurse provide to this client?
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Breastfeed the infant, ensuring that both breasts are completely emptied. Mastitis (caused by plugged milk ducts) is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts , eliminating the pressure on the inflamed breast tissue.
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Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take immediately?
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Place the client in a lateral position. The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by face mask at 10 to 12 L/min. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist/healthcare provider should be notified . immediately
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In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. What statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?
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The anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month (D). These growth and development milestones are frequently included in questions on the licensure exam.
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A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best?
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"That is normal. The head will return to a round shape within 7 to 10 days." reassures the mother that this is normal in the newborn and provides correct information regarding the return to a "normal" shape. NEVER say "Don't Worry".
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A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. A Pitocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol?
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Maternal temperature.Maternal temperature (A) should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital in addition to 8 hours since hospital admission). Delivery is not imminent and there is an increased risk of developing infection 24 hours after ROM.
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A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?
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Move about (around) every hour. Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.
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The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur?
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January 29 to 30. This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30
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A client comes to the OB clinic for her first prenatal visit, and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make?
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"Tell me about these second thoughts you are having about this pregnancy." While ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It is reflective and keeps the lines of communication open.
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A client at 28 weeks of gestation calls the antepartal clinic and states that she just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
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"Come to the clinic today for an ultrasound." Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound . Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus.
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The nurse calls a client who is 4 days postpartum to follow-up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?
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Postpartum blues. During the postpartum period when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues , which peaks around the fifth postpartum day.
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When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
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At 30 weeks of gestation. Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are beginning to anticipate the onset of labor and the birth of their child is an immediate 30 weeks is closest to the time parents would be ready for such classes.
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A nurse receives shift change report for a newborn who is 12 hours post vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?
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Skin color that is slightly jaundiced. Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin which should be further evaluated in a newborn less than 24 hours old.
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When reviewing the laboratory findings of a pregnant woman, the nurse determines that the alpha-fetoprotein (AFP) level is elevated. What information is most important for the nurse to use when interpreting this finding?
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Gestational age. Correct interpretation of concentration of AFP requires precise knowledge of gestational age . High levels after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly.
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Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first?
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Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery .
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A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color and asks when the flow will stop. How should the nurse respond?
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When the placenta site has healed. The placenta site in the uterus usually heals in 3 to 6 weeks, and the lochial flow should cease at that time. Between 2 and 6 weeks after childbirth period, lochia alba occurs in most women . The client is describing lochia serosa, a normal change in the lochial flow between day 3 or 4 after childbirth and lasts to about day 10.
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The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Which score should the nurse assign using this scale?
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5 (five) . The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status—grade 0, 1, or 2 for each component, which includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade one for just visible retractions, which is a total score of 5 .
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A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. What is the correct description of this client that should be documented in the medical record?
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Gravida 2, para 0. This is the client's second pregnancy or second "gravid" event, The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond.
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On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)?
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November 22. correctly applies Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22).
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A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to the baseline after the contraction. What action should the nurse implement?
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Increase the rate of the Pitocin infusion. The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. Fetal heart rate accelerations are a normal response to contractions, so the Pitocin infusion should be increased per protocol to stimulate the frequency and intensity of contractions.
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A newborn infant, diagnosed with congenital hip dysplasia, is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan?
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Observe the parents apply a Pavlik harness. It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness , which keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery.
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During a prenatal visit, the nurse discusses with a client the effects that smoking has on the fetus. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared to the infant of a nonsmoking mother?
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Lower initial weight documented at birth. Smoking is associated with low-birth-weight infants . Therefore, mothers are encouraged not to smoke during pregnancy.
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The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?
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Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.
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An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
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Reassure him that normal maternal/fetal bonding is occurring.These behaviors are positive signs of maternal/fetal bonding and do not reflect ambivalence .
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A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?
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Breastfeed the infant every 2 hours. The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps to extract the milk and relieve some of the discomfort.
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Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
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Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her
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A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV infected. Which explanation should the nurse provide?
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HIV infection is determined at 18 months of age when maternal HIV antibodies are no longer present. All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age when all the maternal antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in the infant within 18 months of age .
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A client at 30 weeks of gestation is on bedrest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and given her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?
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"Take your blood pressure now, and if it is seriously elevated, go to the hospital." Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 or increased by 15 mm Hg diastolic and/or 30 mm Hg systolic is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of PIH.
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Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?
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Allow the cord to air dry as much as possible. Recent studies indicate air drying or plain water application may be equal or more effective than alcohol in the cord healing process .
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The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?
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Avoid alcohol because it is excreted in breast milk. Alcohol should be avoided while breastfeeding because, when consumed by the mother, it is excreted in breast milk and may cause a variety of problems, including growth and mental retardation for the infant.
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A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for the primary side effects of terbutaline sulfate, which are:
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tachycardia and a feeling of nervousness. tachycardia and a feeling of nervousness. Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness"
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The nurse observes an antepartum client, on bedrest for preterm labor, eating ice rather than the food on her breakfast tray. The client states that she has been craving ice and then feels too full to eat anything else. What is the best response by the nurse?
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Notify the healthcare provider. The healthcare provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet and the client should be evaluated for anemia
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Six hours after an oxytocin induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?
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Place the client in a slight Trendelenburg position. The goal is to relieve pressure on the umbilical cord and placing the client in a Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions.
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A client at 32 weeks of gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates that therapeutic drug levels have been achieved?
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Respiratory rate decreases from 24 to 16. Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. However, a respiratory rate below 12 indicates toxic effects. Urinary output must be monitored when administering magnesium sulfate and should be at least 30 ml per hour. . The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
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A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
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Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a "time-out." The mother should be encouraged to comfort the infant and to relax herself .
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Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. What is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line in a newborn?
answer
A cephalhematoma, which is caused by forceps trauma. Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull.
question
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to the baseline after the contraction. What action should the nurse implement?
answer
Increase the rate of the Pitocin infusion. The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. Fetal heart rate accelerations are a normal response to contractions, so the Pitocin infusion should be increased per protocol to stimulate the frequency and intensity of contractions.
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. Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client?
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The client's investment in what is being taught. When teaching any client, readiness to learn is related to how much the client has invested in what is being taught , or how important the material is to their particular life. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about labor and delivery, but is probably very "ready to learn" about ways to relieve morning sickness.
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A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?
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Ensure that the baby is positioned correctly for latch-on. The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latch-on. The baby's body is in alignment with ears, shoulders, and hips in a straight line with nose, cheeks, and chin touching the breast. This helps prevent chafing and nonbinding support aids in prevention of discomfort from the stretching of Cooper's ligament.
