Chapter 14: Caring for the Woman Experiencing Complications During Labor and Birth Nursing School Test Banks

Chapter 14: Caring for the Woman Experiencing Complications During Labor and Birth

MULTIPLE CHOICE

1. The perinatal nurse explains to a nursing student that the most appropriate patient for an amnioinfusion is a woman who has a fetal heart rate tracing that exhibits which pattern?
A. Absent variability
B. Early decelerations
C. Late decelerations
D. Variable decelerations
ANS: D
Pregnancy outcome in patients experiencing variable fetal heart rate decelerations caused by cord compression is improved through the use of amnioinfusion, which is the instillation of normal saline or lactated Ringers solution into the uterine cavity.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. The perinatal nurse notes a rapid decrease in the fetal heart rate (FHR) that does not recover immediately following an amniotomy. What action should the nurse perform first?
A. Administer oxygen at 100%.
B. Assess the maternal temperature.
C. Perform a vaginal examination.
D. Recheck the FHR in 30 minutes.
ANS: C
The nurse needs to assess the fetal heart rate immediately before and after the artificial rupture of the membranes. Changes such as transient fetal tachycardia may occur and are common. However, other fetal heart rate patterns, such as bradycardia and variable decelerations, may be indicative of cord compression or prolapse. The nurse should perform a vaginal examination to assess for cord prolapse. Administering oxygen may or may not be needed. Maternal temperature is assessed every 2 hours after artificial rupture of membranes but is not related to this situation. The nurse should not wait 30 minutes prior to doing anything.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

3. The perinatal nurse has administered a dose of dinoprostone (Cervidil) to a woman prior to a labor induction with oxytocin (Pitocin). The nurse then notices that the admission database is incomplete. What conditions should the nurse quickly question the patient about?
A. Asthma
B. Gallbladder disease
C. IV drug use
D. Penicillin allergy
ANS: A
Dinoprostone is a prostaglandin E2 preparation for cervical ripening. It should be used cautiously in women with a history of asthma, glaucoma, and renal, hepatic, or cardiovascular disorders. Once the missing information is noticed, the nurse should assess for contraindications to using the medication, then for conditions that make it riskier. The other conditions are not related.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

4. During the postpartum assessment, the perinatal nurse notes that a patient who has just experienced a forceps-assisted birth now has a large amount of bright red vaginal bleeding. Her uterine fundus is firm. The most appropriate action by the nurse is to collaborate with the health-care provider in which activity?
A. Bladder assessment and catheterization
B. Preparing the woman for a hysterectomy
C. Uterine massage and oxytocin infusion
D. Vaginal assessment and repair
ANS: D
A forceps-assisted birth is one in which a steel instrument with two curved blades is used to facilitate the birth of the infants head. Perineal trauma is one of the major complications associated with the use of forceps. Because hemorrhage (bright red bleeding) may result from cervical lacerations and vaginal tearing, the woman requires close observation during the postpartum period. If this occurs, the care provider should be notified regarding a potential vaginal repair. The other actions are not warranted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

5. The perinatal nurse is caring for a patient with preeclampsia. What intervention does the nurse include on this patients care plan?
A. Administer magnesium sulfate per agency policy.
B. Assess the patients blood pressure every 6 hours.
C. Encourage the patient to rest on her back.
D. Notify the physician of urine output greater than 30 mL/hr.
ANS: A
The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion. Vital signs should be assessed more often than every 6 hours. The patient should be encouraged to maintain a left side-lying position. A urine output of greater than 30 mL/hour is normal.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

6. The perinatal nurse is providing care to a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 weeks gestation. The nurse is preparing to administer the second dose of betamethasone (Celestone), prescribed by the physician. The patient asks, What is this injection for again? Which of the following is the best response by the nurse?
A. Helps your baby grow and develop
B. Helps your babys lungs to mature
C. Prepares your body to begin labor
D. Stabilizes your blood pressure
ANS: B
Glucocorticoids such as betamethasone are given prior to 34 weeks gestation to promote fetal lung maturity if delivery can be delayed for 48 hours.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

7. The perinatal nurse provides information to a laboring woman with twins that the second twin will normally be born within what time frame?
A. Within 5 minutes of the first twin
B. Within 15 minutes of the first twin
C. Within 30 minutes of the first twin
D. Within 60 minutes of the first twin
ANS: B
The birth of the second twin normally occurs within 15 minutes of the first twin. Although there has been concern over complications associated with a longer time period between births, studies have shown that with proper fetal monitoring and maternal surveillance, a safe vaginal birth can take place in an indefinite amount of time.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

8. The perinatal nurse providing care to a laboring woman recognizes a non-reassuring fetal heart rate tracing. Which of the following is the most appropriate initial action by the nurse?
A. Assist the woman to a left lateral position.
B. Decrease the rate of the intravenous solution.
C. Document the fetal heart rate and variability.
D. Request that the provider apply a fetal scalp electrode.
ANS: A
Because nonreassuring fetal heart rate patterns constitute a risk indicator for cesarean birth, the nurse and all members of the health-care team must be ready for this outcome at all times. The nurse should change the womans position to her side to increase oxygen flow to the fetus. The rate of the IV solution can be increased. Documentation should always be thorough. Fetal scalp electrodes may or may not need to be placed.

Cognitive Level: Application/Application
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment:Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

9. The perinatal nurse is providing care to a multiparous woman in labor. Upon arrival to the birthing suite, the cervix is 5 cm dilated and the patient is experiencing contractions every 1 to 2 minutes that she describes as strong. The patient states that she labored for 1 hour at home and is feeling some rectal pressure. The patient is most likely experiencing what condition?
A. Hypertonic contractions
B. Hypotonic contractions
C. Precipitous labor
D. Uterine hyperstimulation
ANS: C
Precipitous labor contractions produce very rapid, intense contractions. A precipitous labor lasts less than 3 hours from the beginning of contractions to birth. Patients often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

10. The perinatal nurse determines by vaginal examination that a patients cervix is fully dilated and the fetal presenting part is descending rapidly with the patients pushing efforts. The most appropriate nursing intervention at this time would be to do which of the following?
A. Assist the patient with breathing patterns to slow down her pushing.
B. Document the patients progress and coping abilities in labor.
C. Notify the health-care provider to come now for the birth.
D. Provide information to the patients partner about her stage of labor.
ANS: A
This womans labor is progressing precipitously. The nurse should instruct her to breathe through contractions to avoid pushing. Documentation should always be thorough, but further action is needed. The provider should be notified about a possible precipitous birth, but the woman needs assistance to control the bearing-down efforts. The nurse can delegate the notification task to someone else. Patients and their support persons always need information on their progress, but this is not the most important action.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

11. The perinatal nurse is providing care to a 32-year-old G1 TPAL 0000 at 34 weeks gestation. Her blood pressure is 170/100 mm Hg, reflexes are +3, urine is 2+ for protein, and the patient is complaining of a headache. An intravenous solution of magnesium sulfate is begun with an hourly dose of 2 g. Which laboratory value would be assessed most carefully by the nurse?
A. Aspartate aminotransferase (AST)
B. Gamma-glutamyl transpeptidase
C. Hematocrit
D. Neutrophil count
ANS: A
Laboratory tests include a complete blood count with platelets, coagulation profile to assess for disseminated intravascular coagulation, metabolic studies for determination of liver enzymes (aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase), and electrolyte studies to establish renal functioning. The other laboratory values are not as critical in this situation.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

12. The perinatal nurse is caring for a preeclamptic patient at 35 weeks gestation. The patients newest laboratory results include the following: platelet count 98,000/mm3 and RBC 3.1 million/L. What action by the nurse is most appropriate?
A. Administer betamethasone (Celestone).
B. Increase the patients IV fluids.
C. Maintain the patient on bedrest.
D. Notify the health-care provider immediately.
ANS: D
This womans laboratory values indicate the possible development of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which is a factor that may necessitate immediate interventions to facilitate birth. Betamethasone is not given after 34 weeks gestation. Increasing the IV fluids is not warranted. The patient should be maintained on bedrest, but notifying the provider is a priority.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

13. The perinatal nurse is asked to assess a 35-year-old woman who is a G1 TPAL 0000 at 34 weeks gestation with a twin gestation. The patient complains of regular contractions with low abdominal pain that moves into the lumbar section of her back. The perinatal nurses most appropriate initial nursing action is to do which of the following?
A. Assess the patients contractions.
B. Initiate continuous fetal monitoring.
C. Reassure the patient and her partner.
D. Review the patients birth plan.
ANS: B
Electronic fetal monitoring is applied in the case of a multiple gestation. It is important to identify each of the individual fetal heart rates, and the use of a separate monitor for each fetus is preferable. The other interventions are also appropriate, but do not take priority over fetal monitoring.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

14. The nurse is caring for a woman with a placental abruption and suspects the patient has developed disseminated intravascular coagulation (DIC). What interventions does the nurse anticipate?
A. Administering IV fibrinogen
B. Performing hourly vaginal exams to assess for cervical dilation
C. Performing blood pressure assessments every 4 hours
D. Obtaining consent for a cesarean birth
ANS: A
DIC is a severe complication of placental abruption. Interventions include administration of IV cryoprecipitate or fibrinogen. To avoid further tissue damage, pelvic and vaginal exams are not performed. The woman is critically ill, and vital signs need to be monitored more often than every 4 hours. Vaginal birth is desirable unless fetal distress is present or there are other indications. If a cesarean birth is necessary, the nurse will need to place the signed informed consent form on the chart.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

15. The perinatal nurse is providing care to a 17-year-old G2 TPAL 0010 patient at 32 weeks gestation. An ultrasound examination confirms that she is experiencing an abruptio placentae. The patients vital signs are as follows: BP: 110/66 mm Hg, P: 92 beats/minute, R: 18 breaths/minute, fetal heart rate: 156 beats/minute. What assessment should the nurse include in this patients plan of care as a priority?
A. Hourly vital signs
B. Intake and output every 8 hours
C. Blood draw for complete blood count (CBC), prothrombin time (PT), and electrolytes
D. Checks for perineal bleeding every 15 minutes
ANS: C
The nurse should review baseline and ongoing laboratory data, including complete blood count, clotting studies, serum electrolytes, and renal function tests. This baseline information is used to alert the care providers to changes in the patients condition as additional laboratory tests are obtained.
Assessment of vital signs is dependent on the patients condition. Intake and output may need to be monitored more frequently. Checks for bleeding every 15 minutes are not necessary.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

16. The perinatal nurse knows that one of the most severe complications for a patient with a diagnosis of abruptio placentae is which of the following?
A. Couvelaire uterus
B. Hydrops fetalis
C. Hypertension
D. Increased blood volume
ANS: A
Maternal problems resulting from abruptio placentae include a couvelaire uterus (the accumulation of blood between the separated placenta and the uterine wall) and disseminated intravascular coagulation. Although a couvelaire uterus is rare, its implications are severe. The uterus takes on a bluish tinge as blood extravasates from the clot into the myometrium. Contractility is lost. The condition is so severe that a hysterectomy may be necessary to control the bleeding.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

17. A woman reports feeling uterine contractions that are strong, but on subsequent cervical checks, the nurse does not note any changes. What action by the nurse is most appropriate?
A. Assess the woman for causes of anxiety.
B. Attempt an external version of the fetus.
C. Instruct the woman on nipple stimulation.
D. Prepare to administer oxytoxin (Pitocin).
ANS: A
This woman is experiencing hypertonic labor (strong but ineffective contractions). Because maternal anxiety is a major causative factor, the nurse should first assess for anxiety and help to relieve it. A fetal occiput-posterior malposition is also a cause of hypertonic labor, and the nurse should assess for this condition using Leopold maneuvers; however, the health-care provider would perform any attempt at version. Nipple stimulation and oxytocin would be used in hypotonic labor.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

18. A woman has been diagnosed with hypertonic labor. She has an order for hydromorphone (Dilaudid). The student is preparing the medication and asks the labor nurse the rationale for using it. What response by the nurse is best?
A. It is to induce prescribed rest and relax the uterus.
B. Its for the pain associated with those strong contractions.
C. The patient must be allergic to other pain meds.
D. This is the best medication for labor and birth.
ANS: A
Rest, hydration, and sedation often are prescribed in hypertonic labor to reduce the irritability of the uterus and help diminish the ineffective contractions. Medications given include hydromorphone (Dilaudid), meperidine (Demerol), and morphine sulfate (Morphine). The other answers are not accurate.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

19. The nurse is preparing to admit a diabetic woman who is in labor. The nurse plans care to assess carefully for which of the following conditions in this patient?
A. Diminishing uterine contractions
B. Need for an epidural block
C. Onset of intrapartum hypertension
D. Overly strong, painful contractions
ANS: A
Diabetic women are at risk for having a macrosomic infant, which is a risk factor for hypotonic labor. For this patient, the nurse needs to be especially aware of this and assess for less frequent and less intense labor contractions. The other three conditions are not specifically related to diabetes.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

20. A woman is experiencing a long and painful labor and is becoming increasingly intolerant of the pain. She has been receiving frequent, small doses of IV hydromorphone (Dilaudid). The nurse suggests that she switch from medication to massage and water treatments. The patient is reluctant. What explanation by the nurse is best?
A. Its either this or youll need an amniotomy.
B. Pain medicine sometimes slows labor down.
C. You are getting too much pain medication.
D. Your anxiety can cause labor to be slow.
ANS: B
Pharmacological pain interventions can slow the progress of labor, especially if the labor pattern was not well established prior to initiating medication. In order to ease pain and discomfort, the nurse should suggest nonpharmacological measures that should help decrease the amount of pain medication the woman requires. The other statements are not accurate, and telling the woman she has to choose between relaxation techniques or amniotomy sounds vaguely threatening.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

21. A woman had an amniotomy 1 hour ago. Now she is complaining of uterine tenderness. What action by the nurse is most appropriate?
A. Increase the IV infusion rate.
B. Notify the health-care provider.
C. Perform a vaginal examination.
D. Take the womans temperature.
ANS: D
An amniotomy is an invasive procedure that carries the risk of infection. Maternal temperature should be assessed at least every 2 hours afterward. Other signs of infection include uterine tenderness, chills, foul-smelling vaginal discharge, and fetal tachycardia. The nurse should first assess the womans temperature (and assess for other signs of infection) and then notify the health-care provider. The other two options would not be indicated at this time.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

22. A nulliparous woman has been admitted to the labor and birth unit. Her Bishop score is 4. What medication does the nurse plan to administer?
A. Betamethasone (Celestone)
B. Hydromorphone (Dilaudid)
C. Misoprostol (Cytotec)
D. Oxytocin (Pitocin)
ANS: C
The Bishop score is a rating system used to determine the level of cervical inducibility. Labor induction is more likely to be successful with a higher score (9 or more for nulliparous women; 5 for multiparous women). This womans cervix is not favorable for induction, so a cervical ripening agent should be used. Cytotec is one such agent. Betamethasone is used to improve fetal lung maturity. Hydromorphone is a pain medication. Oxytocin would be used to augment labor once the cervix is favorable.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Planning
Difficulty: Moderate

PTS: 1

23. A nurse is caring for a woman who will be induced, but her cervix is not yet favorable for this intervention. The provider leaves an order for dinoprostone vaginal insert (Cervidil), which the nurse administers at 9:00 a.m. At what time does the nurse anticipate induction with oxytocin (Pitocin)?
A. In 30 to 60 minutes after the last dose of dinoprostone
B. In 30 to 60 minutes after the dinoprostone insert is removed
C. In 5 to 7 hours or when contractions begin
D. In 6 to 12 hours after the dinoprostone insert is removed
ANS: B
After Cervidil administration, contractions usually begin within 5 to 7 hours. If further augmentation is needed with oxytocin, it can be administered 30 to 60 minutes after the dinoprostone vaginal insert is removed.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

24. A nurse has administered dinoprostone gel (Prepidil) to a nulliparous woman whose Bishop score is 5. Fifteen minutes later the patient complains of intense itching, vaginal burning, and shortness of breath. What medication does the nurse anticipate giving?
A. Epinephrine (Adrenalin)
B. Hydromorphone (Dilaudid)
C. Misoprostol (Cytotec)
D. Terbutaline (no brand name)
ANS: D
In case of adverse reactions to dinoprostone, the nurse will administer terbutaline, 0.25 mg intravenously or subcutaneously. The other medications are not indicated.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

25. A nurse is caring for a patient who had a laminaria tent inserted 6 hours ago. What action by the nurse is most appropriate?
A. Assess and record maternal temperature.
B. Document fetal and maternal heart rate.
C. Perform an amniotic membrane stripping.
D. Remove the laminaria tent and assess cervical dilation.
ANS: D
A laminaria tent is a hydroscopic cervical dilator made of seaweed, which swells as it absorbs moisture. Hydroscopic dilators remain in place for 6 to 12 hours, after which time they are removed and the woman is assessed for cervical dilation. The other interventions are not specific to this type of dilator.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

26. A woman is receiving oxytocin (Pitocin) via infusion. The nurse assesses the following: uterine contractions lasting 100 seconds every 1.5 minutes, uterine resting tone 36 mm Hg, baseline fetal heart rate (FHR) 108 beats/minute with absent variability. What action by the nurse takes priority?
A. Document the findings.
B. Notify the provider.
C. Reassess the FHR in 10 minutes
D. Stop the infusion.
ANS: D
Oxytocin can cause uterine tachysystole, and the nurses assessments are consistent with this condition. The priority action by the nurse is to stop the infusion. The nurse should notify the provider. Documentation should be thorough. Reassessment should be driven by a written protocol.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

27. A nurse has instructed a woman on the procedure for nipple rolling. What action by the patient demonstrates good understanding of the teaching?
A. Pinches and pulls the nipples on alternating sides
B. Rolls both nipples together for 10 minutes
C. Rolls one nipple at a time during a contraction
D. Rolls one nipple at a time through her clothing
ANS: D
Nipple rolling can stimulate uterine contractions after labor has begun. The technique is used when labor is not progressing satisfactorily. The nurse instructs the patient to roll one nipple at a time for 10 minutes through her clothing. Then she should switch to the other side. The woman should rest during contractions.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

28. A new nurse is working with a patient undergoing an induction of labor. What action by the new nurse would prompt the preceptor to intervene?
A. Assesses contractions every 5 minutes in the second stage of labor
B. Calculates and charts the maternal total urine output every 4 hours
C. Documents an IV intake of 1,500 mL in 8 hours
D. Records the maternal vital signs a minimum of every 60 minutes
ANS: C
During an induction of labor, the IV fluid intake should not exceed 1,000 mL in 8 hours to prevent fluid overload after the placenta is delivered. If the new nurse has documented a larger amount, the preceptor needs to intervene. The other options show proper care of this patient.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

29. A nurse is assisting with a forceps delivery. After the forceps are applied, the nurse notes fetal bradycardia. What action by the nurse takes priority?
A. Assess the fetal heart rate in 5 minutes.
B. Document the findings in the chart.
C. Inform the health-care provider immediately.
D. Turn the woman on her left side.
ANS: C
When the forceps are applied, umbilical cord compression can occur. Compression of the cord causes a decrease in the fetal heart rate. The nurse should immediately inform the provider so that the pressure can be released. The nurse is responsible for documenting the fetal heart rate before and immediately after forceps application, but relieving the pressure on the umbilical cord takes priority. The nurse should not wait 5 minutes for another assessment, nor should the nurse turn the patient on her side as a first action.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

30. A nurse is caring for a pregnant woman with diabetes mellitus. What assessment finding demonstrates that the patient has successfully met an important goal during pregnancy?
A. Blood glucose consistently < 130 mg/dL
B. Electrolyte levels remaining within normal limits
C. Fetal weight > 4,500 g at birth
D. Pregnancy weight gain of no more than 20 lb
ANS: A
Women with diabetes should strive to maintain their blood glucose readings within normal parameters during pregnancy. Poor glycemic control contributes to fetal macrosomia (fetal weight > 500 g) and other complications. Weight gain should not be restricted to 20 lb, and electrolyte readings are not related to a major goal for this woman.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

31. A woman at 30 weeks gestation is 80% effaced and 5 cm dilated. Which action by the nurse takes priority?
A. Arrange a palliative care consult for probable fetal demise.
B. Encourage the woman to attempt a trial of labor before undergoing a cesarean section.
C. Ensure that informed consent for a cesarean birth is on the chart.
D. Inform the woman that if the tocolytic therapy is successful, she will deliver.
ANS: C
In preterm labor, if the womans membranes have ruptured or if her cervix is more than 50% effaced and 34 cm dilated, it is not likely that the labor can be stopped. A cesarean birth is preferable to a vaginal delivery because it diminishes pressure on the fetal head and decreases the risk of intracranial hemorrhage. Because there is a high likelihood of cesarean birth, the nurse should ensure that consent for cesarean delivery is on the chart, in the event that the labor cannot be halted. Tocolytic medications are administered to halt contractions; if unsuccessful, the birth will occur.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

32. A woman is about to undergo an external version. What action by the nurse takes priority?
A. Determine Rh status; give Rh immune globulin if needed.
B. Explain the procedure to the woman and obtain consent.
C. Offer emotional support to both the woman and her partner.
D. Prepare to administer oxytocin (Pitocin) as per protocol.
ANS: A
Because the version can cause feto-maternal bleeding, women who are Rh-negative should receive Rh immune globulin (RhoGAM). Offering emotional support is always important, but does not take priority over keeping the patient safe. The physician is responsible for explaining the procedure. Because uterine relaxation is important for a successful version, tocolytic medications may be given (not medications that increase uterine tone).

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

33. A nurse is caring for a woman who gave birth to a term infant an hour ago. The chart notes that the baby was born after demonstrating a positive turtle sign. What assessment finding by the nurse warrants immediate action?
A. Lochia rubra is noted an hour after birth.
B. Maternal blood pressure is 90/42 mm Hg.
C. Maternal heart rate is 68 beats/minute.
D. Patient saturates one perineal pad in 2 hours.
ANS: B
A turtle sign describes a situation where the fetal head retracts during contractions after crowning. This is a clinical indicator of possible shoulder dystocia. Maternal complications of shoulder dystocia include hemorrhage and soft tissue trauma. A blood pressure as low as this womans blood pressure measurement could be an indicator of hemorrhage, and the nurse needs to assess the woman further. The finding of lochia rubra 1 hour after birth is normal, as is a maternal heart rate of 68 beats/ minute. The finding of one saturated perineal pad within 2 hours is also normal.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

34. A woman has just given birth to an infant whose 1-minute Apgar score was 9. Meconium-stained amniotic fluid was noted upon rupture of the membranes. What action by the nurse is most appropriate?
A. Apply oxygen at 0.5 L/minute via face mask.
B. Assess and document the infants 5-minute Apgar score.
C. Transfer the neonate to the intensive care unit.
D. Vigorously suction the infants trachea.
ANS: B
Vigorous infants born in the presence of meconium-stained amniotic fluid do not need routine tracheal suctioning after birth. An Apgar score of 9 indicates that this baby is not depressed, so the nurse should continue to provide routine care for the infant and assess the 5-minute Apgar score. The other interventions are not warranted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Care Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

35. A nurse is caring for a patient with abruptio placentae. What assessment findings would indicate that the woman is hemodynamically stable?
A. Fetal heart rate: 108 beats/minute
B. Hematocrit: 33%
C. Oxygen saturation: 90%
D. Urine output: 20 mL/hour
ANS: B
Hemorrhage is a significant possibility with placental abruption. A hematocrit less than 30% is indicative of maternal hemodynamic stability; the presence of fetal bradycardia, maternal hypoxia, and urine output less than 30 mL/hour are indicative of an unstable state.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

36. A laboring woman complains of sudden, sharp, severe pain during a contraction, and when the contraction ceases, the pain is gone. What assessment by the nurse takes priority?
A. Abdominal palpation
B. Fetal heart tracing
C. Maternal vital signs
D. Intrauterine pressure
ANS: B
A ruptured uterus is an obstetrical emergency. A classic sign is sudden pain during a contraction that ceases abruptly. Uterine rupture may be incomplete and the woman may be asymptomatic. Changes in fetal heart tracings (e.g., sudden bradycardia, prolonged late or variable decelerations) are the most common signs and symptoms and frequently precede the onset of maternal symptoms (i.e., pain, bleeding). Although all assessments are appropriate, the first thing the nurse should do is assess the fetal heart tracings.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

37. A womans membranes have just ruptured and she states I feel something in my vagina. The nurse assesses the woman and sees part of the umbilical cord protruding from the vagina. What action by the nurse is best?
A. Cover the cord with warm sterile saline-soaked compresses.
B. Push the cord segment back into the vagina.
C. Position the woman in reverse Trendelenburg.
D. Take the maternal and fetal vital signs.
ANS: A
Exposure to room air will cause the umbilical cord to dry out, leading to atrophy of the umbilical vessels. The nurse should not attempt to replace the cord but should cover it with a warm, saline-soaked sterile compress. The nurse should also exert upward pressure on the presenting part to relieve cord compression and prevent fetal hypoxia. The woman should be positioned in extreme Trendelenburg, modified Sims, or knee-chest position to take pressure off the cord. Assessing maternal and fetal signs is important, but first the nurse needs to preserve the cord.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

38. When caring for a laboring patient, the nurse notes the onset of sudden vaginal bleeding at the beginning of cervical dilation. The patient denies any pain. What action by the nurse is best?
A. Document the findings in the womans chart.
B. Place the woman in a knee-chest position.
C. Prepare the woman for an immediate cesarean birth.
D. Perform a careful vaginal exam to assess for exposed umbilical cord vessels.
ANS: D
This woman has the classic sign of vasa previa, in which the unprotected fetal vessels cover the cervical os and precede the fetus. This condition is usually seen with a velamentous insertion of the umbilical cord. The nurse should conduct a careful vaginal exam, assessing for exposed fetal blood vessels. The patient may need an emergent cesarean delivery. This assessment should come prior to interventions such as positioning.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

39. A nurse assisting in a birth observes the patient suddenly fall back against the bed and become unresponsive. What action by the nurse takes priority?
A. Assess airway, breathing, and circulation.
B. Begin immediate cardiopulmonary resuscitation.
C. Insert an indwelling urinary catheter.
D. Prepare for an emergency cesarean delivery.
ANS: A
In any emergency situation, such as an unresponsive patient, the nurse needs to assess airway, breathing, and circulation and begin providing CPR if needed. The patient may or may not need an emergency cesarean delivery. Inserting a urinary catheter is not the priority.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

40. The perinatal nurse explains to a nursing student that perinatal loss occurs when a womans baby is lost during what time period?
A. Any time during the first year of life
B. From conception through birth
C. From conception through the first 28 days after birth
D. During labor or delivery
ANS: C
Perinatal loss is defined as the death of a fetus or infant from the time of conception through the end of the newborn period, 28 days after birth.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

41. The nurse manager of the perinatal services unit wants to improve outcomes associated with perinatal loss. What action by the manager would best help meet this goal?
A. Develop a unit specifically for this population.
B. Establish a multidisciplinary perinatal loss team.
C. Identify key nurses to care for these patients.
D. Provide debriefing services for the nursing staff.
ANS: B
A team approach to perinatal loss and bereavement is best to provide a therapeutic and caring experience for families suffering perinatal loss. The families are best cared for by expert perinatal nurses. Because perinatal loss is not common, developing a unit for this population would not be cost effective. Instead of identifying key nurses to care for these patients and families, the support of an entire team trained to deal with this situation is better. Outcomes should be patient/family oriented, not staff oriented.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

42. A new nurse is struggling to care for a woman whose baby was stillborn. What advice should the nurse preceptor give the novice?
A. Dont say anything; thats better than upsetting her.
B. Encourage the mother to think of her other children.
C. Why dont you let me take care of this patient?
D. You can simply say I am so sorry for your loss.
ANS: D
A simple Im sorry and a touch of the hand are kind and caring interactions. The novice nurse should not be instructed to avoid saying anything because the woman will want her loss (and baby) recognized. The nurse should not just encourage the woman to think of her other children, as this is dismissive of her loss. Taking over care of the patient will not allow the novice nurse to grow as a professional.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

43. A woman has experienced a stillbirth and is now nearing term in her current pregnancy. The husband confides to the nurse: My wife is driving me crazy. She is totally obsessed with this pregnancy. What response by the nurse is best?
A. Do you think your wife could benefit from some counseling?
B. Recent research has shown that this is a common behavior.
C. This is a totally normal response and will be over soon.
D. You can always go out fishing or bowling when it is too much.
ANS: B
Recent research by Nowak and Stevens (2010) demonstrates that watchful vigilance is a common and important behavior in couples at risk for adverse perinatal outcomes. The nurse should share this information with the husband. Telling him that the behavior is common and will go away does not really give him information about this issue. The woman does not need counseling unless there are other, more alarming, behaviors occurring. Telling the husband to go fishing or bowling is dismissive.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

44. A woman is G2P1 TPAL1001and pregnant with her second child. Her first child was born via emergent cesarean delivery. She asks the nurse if a vaginal birth is possible. What response by the nurse is most appropriate?
A. No, after cesarean birth you cannot delivery vaginally.
B. Not if your cesarean delivery was the classic-style operation.
C. Yes, you can always at least have a trial of labor.
D. Yes, vaginal birth is usually successful after cesarean deliveries.
ANS: B
There are two types of cesarean delivery: classic (vertical incision) and the lower segment transverse incision. Classic-style incisions are reserved for some cases of shoulder dystocia, placental previa, and when birth must take place emergently. The nurse needs to determine if the woman had a classic cesarean delivery when her first child was delivered emergently. If so, the woman cannot attempt a vaginal delivery. Women with a low transverse incision can safely attempt a trial of labor.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

45. A woman arrives at the birthing unit for a scheduled cesarean birth. What action by the nurse is most important?
A. Cleanse and shave the womans abdomen.
B. Ensure that signed informed consent is on the chart.
C. Facilitate a blood draw for type and cross match.
D. Initiate a large-bore IV and insert a catheter.
ANS: B
Upon arrival to the birthing unit, the priority nursing action is to ensure that a signed maternal consent is on the chart. The nurse will cleanse and shave the abdomen, start an IV, and insert a catheter, but these interventions are not the priority. Laboratory work should have been obtained prior to the day of admission.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

46. After a cesarean delivery under general anesthesia, which assessment by the nurse is most critical?
A. Airway
B. Circulation
C. Lochia
D. Vital signs
ANS: A
Airway always comes first. The other assessments are important, but nothing takes priority over assessment of the airway.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

47. A woman is admitted to the birthing unit in her 42nd week of pregnancy. What interventions does the nurse plan for this patient?
A. Frequent vaginal checks
B. Care for the patient undergoing a labor induction
C. Emotional support while awaiting delivery
D. Preparation for cesarean delivery
ANS: B
This woman is 2 weeks postterm and due to the deterioration of the placenta and subsequent fetal hypoxia, she has been admitted for induction. Emotional support is always necessary, but the nurse needs to be prepared to do more than just offer emotional support. Frequent vaginal checks are not indicated in the nonlaboring patient. This woman may or may not need a cesarean delivery.

Cognitive Level: Applying/Application
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

48. A pregnant woman is admitted to the high-risk OB unit and started on an IV of magnesium sulfate (Sulfamag). What assessment by the nurse is most important?
A. Deep tendon reflexes (DTRs)
B. Fetal heart tones
C. Serum calcium level
D. Temperature
ANS: A
Sulfamag can lead to muscle weakness. A critical assessment while using this drug is DTRs. The other assessments are not related to side effects of this drug.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

MULTIPLE RESPONSE

1. The perinatal nurse is explaining to a nursing student that which of the following are problems more frequently associated with twin gestation births? (Select all that apply.)
A. Adherent placentas and bleeding
B. Intrauterine growth restriction
C. Long-term fetal disabilities
D. Abnormal fetal presentations
E. Requirement for cesarean delivery
ANS: A, B, C, D
Twins and higher-order multiple-gestation births are associated with more maternal and fetal
complications, including excessive bleeding from adherent placentas, intrauterine growth restriction, long-term fetal disabilities such as cerebral palsy, and multiple fetal presentations. A woman with twins who presents at 38 weeks gestation or later may be a candidate for a vaginal delivery.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. The nurse is explaining dysfunctional labor patterns to a group of nursing students. Which of the following should the nurse include in the list of risk factors for hypotonic labor? (Select all that apply.)
A. Anxiety and fear
B. Fetal malpresentation
C. Maternal obesity
D. Multiple gestation
E. Pain medication
ANS: B, C, D, E
Many factors contribute to hypotonic labor, including fetal anomalies, malpresentation, and macrosomia; maternal diabetes and hypertension; multiple gestation; and hydramnios. Anxiety and fear are more likely contributing factors to hypertonic labor.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

3. A nurse is caring for a woman who has an order for a high-dose oxytocin (Pitocin) regimen to stimulate uterine contractions. Which of the following actions are appropriate for the nurse to take? (Select all that apply.)
A. Assess frequently for uterine tachysystole.
B. Increase the infusion every 30 minutes as needed.
C. Place to woman prone to prevent dizziness.
D. Start the infusion at 2 mU/minute.
E. Use an electronic infusion device.
ANS: A, B, E
Oxytocin must be administered safely. The high-dose regimen begins with 4 mU/minute and is increased by the same amount every 30 minutes as needed. Uterine tachysystole can occur and the nurse must assess carefully for the development of this situation. The woman is placed sitting upright or in a side-lying position. Oxytocin should always be infused via an electronic infusion device.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Intervention
Difficulty: Difficult

PTS: 1

4. The nurse is caring for a woman who is undergoing an induction with oxytocin (Pitocin). The nurse explains to a nursing student that contraindications to labor induction include which of the following? (Select all that apply.)
A. Active genital herpes infection
B. Breech presentation
C. History of a myomectomy
D. Severe hypertension
E. Vasa previa or complete placenta previa
ANS: A, C, E
Absolute contraindications for induction of labor include vasa previa or complete placenta previa, transverse fetal lie, umbilical cord prolapse, previous classical cesarean delivery, active genital herpes infection, and previous myomectomy. Breech presentation and severe hypertension are relative contraindications, meaning that induction is possible, but caution should be exercised.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

5. A perinatal nurse is aware that which of the following fetal conditions places a woman at risk for oligohydramnios? (Select all that apply.)
A. Fetal renal abnormalities
B. Maternal diabetes
C. Multiple gestations
D. Poor placental perfusion
E. Premature rupture of membranes
ANS: A, D, E
Conditions that increase the risk of oligohydramnios include fetal renal abnormalities, poor placental perfusion, and premature rupture of membranes. Maternal diabetes and multiple gestation are risk factors for (poly)hydramnios.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

6. A nurse is working with a nulliparous woman diagnosed with placenta previa. What interventions should the nurse plan to implement if necessary? (Select all that apply.)
A. Educate the woman about prenatal iron supplements.
B. Facilitate informed consent for blood.
C. Educate the woman about the need for a forceps delivery.
D. Explain that she will undergo a planned delivery at 3435 weeks.
E. Advise the woman that a vaginal birth may be possible.
ANS: A, B, E
Interventions that are appropriate for women diagnosed with placenta previa include instruction about the need for prenatal iron and folic acid supplementation. Hemorrhage is possible, so a consent form for blood products may be needed. A forceps delivery is not indicated. Women with suspected placenta accreta should be delivered between 34 and 35 weeks; those with placenta previa should be delivered at 36 to 37 weeks. Women diagnosed with a partial or marginal placenta previa who have no bleeding or minimal bleeding may be allowed to attempt a vaginal birth.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

7. A nursing professor is describing placental abruption to a class of nursing students. What information is included? (Select all that apply.)
A. Cesarean delivery is almost always needed.
B. Complications include couvelaire uterus and DIC.
C. Fetal and maternal death may occur.
D. Hysterectomy may be necessary to control bleeding.
E. Pelvic and vaginal exams are not performed.
ANS: B, C, D, E
Placental abruption is a serious condition that can lead to both fetal and maternal death. Other complications include couvelaire uterus and DIC. Bleeding may be so severe that a hysterectomy is needed. To prevent further damage, vaginal and pelvic exams are not performed. Vaginal birth is desirable; cesarean birth is reserved for cases of fetal distress or other obstetric indications and should not be attempted if the woman has severe and uncorrected coagulopathy.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

8. The nurse assesses a patient suspected of having disseminated intravascular coagulation (DIC) for which of the following symptoms? (Select all that apply.)
A. Blood in the Foley catheter bag
B. Slight oozing from an IV site
C. Spontaneous nosebleed
D. Tachycardia
E. Widespread bruising
ANS: A, C, D, E
DIC includes both bleeding and thrombotic manifestations. Blood in the urine, spontaneous nosebleeds, tachycardia, and widespread bruising are all manifestations that could signal DIC. Slight oozing from an IV site is a common finding, and without bleeding noted at multiple sites, it is probably insignificant.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

9. What actions by the nursing staff would be beneficial for parents who have lost a newborn? (Select all that apply.)
A. Ask the babys name and use it.
B. Clean the infant and wrap in a blanket.
C. Encourage them not to see their baby.
D. Explain how the infant will look.
E. Take photographs to give the parents.
ANS: A, B, D, E
Perinatal loss is difficult for all concerned. Some interventions that have been found to be helpful include acknowledging the baby as a person by using his or her name; cleaning the baby and wrapping him or her in a blanket or dressing the child appropriately (so the baby looks warm and tended to); explaining how the baby will look, especially if the child does not have normal features; and giving the parents photographs and other memorabilia of their child. If the child is not in a favorable condition for photographs, a professional photographer is important. The family should always be encouraged to hold, touch, and cuddle the baby after death.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Easy

PTS: 1

10. A woman is asking about a cesarean birth. The nurse explains that which of the following are appropriate indications for this type of birth? (Select all that apply.)
A. Active genital herpes
B. Certain fetal malpresentations
C. Maternal request
D. Some multiple gestations
E. Umbilical cord prolapse
ANS: A, B, D, E
Cesarean birth should be reserved for instances where the health of the mother or her fetus is jeopardized. Many conditions can lead to the need for a cesarean birth, but maternal request is not one of them.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

11. The nurse explains to a class of nursing students that which of the following are the main predictors of medically indicated and elective cesarean birth? (Select all that apply.)
A. Use of assisted reproductive technology
B. Induced labor before 39 weeks of gestation
C. Maternal age greater than 35
D. Multiple-gestation pregnancy
E. Native American ethnicity
ANS: A, B, C, D
The main predictors of elective or medically indicated cesarean births are assisted reproductive technology, induced labor prior to 39 weeks gestation, maternal age older than 35, and multiple-gestation pregnancy (especially higher-order multiples). Native Americans have only a 28% rate of cesarean delivery, the lowest among major ethnic groups.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

12. The nurse is teaching a childbirth preparation class for women who will have planned cesarean births for medical need. What potential complications of this operation does the nurse describe?
A. Chronic pain
B. Sexual dysfunction
C. Subsequent placental problems
D. Urinary tract injury
E. Wound dehiscence
ANS: A, C, D, E
There are many possible maternal complications to cesarean birth, including chronic pain, placental problems in subsequent pregnancies, urinary tract injury, wound dehiscence, and adhesions. Sexual dysfunction is not a typical complication.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

13. A G2P1 woman wishes to have a trial of labor after a previous low-transverse cesarean delivery. What factors would permit the woman to be allowed this trial of labor? (Select all that apply.)
A. Adequate pelvis size related to fetal size
B. Desire to use epidural analgesia
C. Patient free of any chronic illnesses
D. No history of uterine abnormalities
E. Physician available throughout the trial who is capable of performing a cesarean delivery
ANS: A, B, D, E
Criteria for allowing a trial of labor include one previous cesarean birth (if two prior cesarean births, only those who have also had a vaginal birth should be allowed a trial of labor), no history of uterine abnormalities, an available physician who is present during the active phase of the labor trial and who is capable of monitoring and performing an emergency cesarean delivery, and availability of other personnel such as an anesthesiologist. Epidural analgesia may be used as part of a trial of labor after cesarean. Absence of any chronic illnesses is not a criterion.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

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