Maternal & Child Health Nursing NCLEX part 5
All our efforts are to help to get your knowledge in easy, convenient and efficient way. Use our free study materials and help others to get these materials. Wish you get success in your carrier.
Join our telegram: https://t.me/thebossacademynet
PDF format, Answers and Rationales are available at the end of this questions.
Intrapartum
1. A nurse is caring for a client in labor. The nurse
determines that the client is beginning in the second stage of labor when which
of the following assessments is noted?
A. The client begins to expel clear vaginal fluid
B. The contractions are regular
C. The membranes have ruptured
D. The cervix is dilated completely
2. A nurse in the labor room is caring for a client in
the active phases of labor. The nurse is assessing the fetal patterns and notes
a late deceleration on the monitor strip. The most appropriate nursing action
is to:
A. Place the mother in the supine position
B. Document the findings and continue to monitor the
fetal patterns
C. Administer oxygen via face mask
D. Increase the rate of Pitocin IV infusion
3. A nurse is performing an assessment of a client who
is scheduled for a cesarean delivery. Which assessment finding would indicate a
need to contact the physician?
A. Fetal heart rate of 180 beats per minute
B. White blood cell count of 12,000
C. Maternal pulse rate of 85 beats per minute
D. Hemoglobin of 11.0 g/dL
4. A client in
labor is transported to the delivery room and is prepared for a cesarean
delivery. The client is transferred to the delivery room table, and the nurse
places the client in the:
A. Trendelenburg’s position with the legs in stirrups
B. Semi-Fowler position with a pillow under the knees
C. Prone position with the legs separated and elevated
D. Supine position with a wedge under the right hip
5. A nurse is caring for a client in labor and
prepares to auscultate the fetal heart rate by using a Doppler ultrasound
device. The nurse most accurately determines that the fetal heart sounds are
heard by:
A. Noting if the heart rate is greater than 140 BPM
B. Placing the diaphragm of the Doppler on the
mother’s abdomen
C. Performing Leopold’s maneuvers first to determine
the location of the fetal heart
D. Palpating the maternal radial pulse while listening
to the fetal heart rate
6. A nurse is caring for a client in labor who is
receiving Pitocin by IV infusion to stimulate uterine contractions. Which
assessment finding would indicate to the nurse that the infusion needs to be
discontinued?
A. Three contractions occurring within a 10-minute
period
B. A fetal heart rate of 90 beats per minute
C. Adequate resting tone of the uterus palpated
between contractions
D. Increased urinary output
7. A nurse is beginning to care for a client in labor.
The physician has prescribed an IV infusion of Pitocin. The nurse ensures that
which of the following is implemented before initiating the infusion?
A. Placing the client on complete bed rest
B. Continuous electronic fetal monitoring
C. An IV infusion of antibiotics
D. Placing a code cart at the client’s bedside
8. A nurse is monitoring a client in active labor and
notes that the client is having contractions every 3 minutes that last 45
seconds. The nurse notes that the fetal heart rate between contractions is 100
BPM. Which of the following nursing actions is most appropriate?
A. Encourage the client’s coach to continue to
encourage breathing exercises
B. Encourage the client to continue pushing with each
contraction
C. Continue monitoring the fetal heart rate
D. Notify the physician or nurse midwife
9. A nurse is caring for a client in labor and is
monitoring the fetal heart rate patterns. The nurse notes the presence of
episodic accelerations on the electronic fetal monitor tracing. Which of the
following actions is most appropriate?
A. Document the findings and tell the mother that the
monitor indicates fetal well-being
B. Take the mother’s vital signs and tell the mother
that bed rest is required to conserve oxygen.
C. Notify the physician or nurse-midwife of the
findings.
D. Reposition the mother and check the monitor for
changes in the fetal tracing
10. A nurse is admitting a pregnant client to the
labor room and attaches an external electronic fetal monitor to the client’s
abdomen. After attachment of the monitor, the initial nursing assessment is
which of the following?
A. Identifying the types of accelerations
B. Assessing the baseline fetal heart rate
C. Determining the frequency of the contractions
D. Determining the intensity of the contractions
11. A nurse is reviewing the record of a client in the
labor room and notes that the nurse midwife has documented that the fetus is at
(-1) station. The nurse determines that the fetal presenting part is:
A. 1 cm above the ischial spine
B. 1 fingerbreadth below the symphysis pubis
C. 1 inch below the coccyx
D. 1 inch below the iliac crest
12. A pregnant client is admitted to the labor room.
An assessment is performed, and the nurse notes that the client’s hemoglobin
and hematocrit levels are low, indicating anemia. The nurse determines that the
client is at risk for which of the following?
A. A loud mouth
B. Low self-esteem
C. Hemorrhage
D. Postpartum infections
13. A nurse assists in the vaginal delivery of a
newborn infant. After the delivery, the nurse observes the umbilical cord
lengthen and a spurt of blood from the vagina. The nurse documents these
observations as signs of:
A. Hematoma
B. Placenta previa
C. Uterine atony
D. Placental separation
14. A client arrives at a birthing center in active
labor. Her membranes are still intact, and the nurse-midwife prepares to
perform an amniotomy. A nurse who is assisting the nurse-midwife explains to
the client that after this procedure, she will most likely have:
A. Less pressure on her cervix
B. Increased efficiency of contractions
C. Decreased number of contractions
D. The need for increased maternal blood pressure
monitoring
15. A nurse is monitoring a client in labor. The nurse
suspects umbilical cord compression if which of the following is noted on the
external monitor tracing during a contraction?
A. Early decelerations
B. Variable decelerations
C. Late decelerations
D. Short-term variability
16. A nurse explains the purpose of effleurage to a
client in early labor. The nurse tells the client that effleurage is:
A. A form of biofeedback to enhance bearing down
efforts during delivery
B. Light stroking of the abdomen to facilitate
relaxation during labor and provide tactile stimulation to the fetus
C. The application of pressure to the sacrum to
relieve a backache
D. Performed to stimulate uterine activity by
contracting a specific muscle group while other parts of the body rest
17. A nurse is caring for a client in the second stage
of labor. The client is experiencing uterine contractions every 2 minutes and
cries out in pain with each contraction. The nurse recognizes this behavior as:
A. Exhaustion
B. Fear of losing control
C. Involuntary grunting
D. Valsalva’s maneuver
18. A nurse is monitoring a client in labor who is
receiving Pitocin and notes that the client is experiencing hypertonic uterine
contractions. List in order of priority the actions that the nurse takes.
A. Stop of Pitocin infusion
B. Perform a vaginal examination
C. Reposition the client
D. Check the client’s blood pressure and heart rate
E. Administer oxygen by face mask at 8 to 10 L/min
19. A nurse is assigned to care for a client with
hypotonic uterine dysfunction and signs of a slowing labor. The nurse is
reviewing the physician’s orders and would expect to note which of the
following prescribed treatments for this condition?
A. Medication that will provide sedation
B. Increased hydration
C. Oxytocin (Pitocin) infusion
D. Administration of a tocolytic medication
20. A nurse in the labor room is preparing to care for
a client with hypertonic uterine dysfunction. The nurse is told that the client
is experiencing uncoordinated contractions that are erratic in their frequency,
duration, and intensity. The priority nursing intervention would be to:
A. Monitor the Pitocin infusion closely
B. Provide pain relief measures
C. Prepare the client for an amniotomy
D. Promote ambulation every 30 minutes
21. A nurse is developing a plan of care for a client
experiencing dystocia and includes several nursing interventions in the plan of
care. The nurse prioritizes the plan of care and selects which of the following
nursing interventions as the highest priority?
A. Keeping the significant other informed of the
progress of the labor
B. Providing comfort measures
C. Monitoring fetal heart rate
D. Changing the client’s position frequently
22. A maternity nurse is preparing to care for a
pregnant client in labor who will be delivering twins. The nurse monitors the
fetal heart rates by placing the external fetal monitor:
A. Over the fetus that is most anterior to the
mother’s abdomen
B. Over the fetus that is most posterior to the
mother’s abdomen
C. So that each fetal heart rate is monitored
separately
D. So that one fetus is monitored for a 15-minute
period followed by a 15 minute fetal monitoring period for the second fetus
23. A nurse in the postpartum unit is caring for a
client who has just delivered a newborn infant following a pregnancy with
placenta previa. The nurse reviews the plan of care and prepares to monitor the
client for which of the following risks associated with placenta previa?
A. Disseminated intravascular coagulation
B. Chronic hypertension
C. Infection
D. Hemorrhage
24. A nurse in the delivery room is assisting with the
delivery of a newborn infant. After the delivery of the newborn, the nurse
assists in delivering the placenta. Which observation would indicate that the
placenta has separated from the uterine wall and is ready for delivery?
A. The umbilical cord shortens in length and changes
in color
B. A soft and boggy uterus
C. Maternal complaints of severe uterine cramping
D. Changes in the shape of the uterus
25. A nurse in the labor room is performing a vaginal
assessment on a pregnant client in labor. The nurse notes the presence of the
umbilical cord protruding from the vagina. Which of the following would be the
initial nursing action?
A. Place the client in Trendelenburg’s position
B. Call the delivery room to notify the staff that the
client will be transported immediately
C. Gently push the cord into the vagina
D. Find the closest telephone and stat page the
physician
26. A maternity nurse is caring for a client with
abruptio placenta and is monitoring the client for disseminated intravascular
coagulopathy. Which assessment finding is least likely to be associated with
disseminated intravascular coagulation?
A. Swelling of the calf in one leg
B. Prolonged clotting times
C. Decreased platelet count
D. Petechiae, oozing from injection sites, and hematuria
27. A nurse is assessing a pregnant client in the 2nd
trimester of pregnancy who was admitted to the maternity unit with a suspected
diagnosis of abruptio placentae. Which of the following assessment findings
would the nurse expect to note if this condition is present?
A. Absence of abdominal pain
B. A soft abdomen
C. Uterine tenderness/pain
D. Painless, bright red vaginal bleeding
28. A maternity nurse is preparing for the admission
of a client in the 3rd trimester of pregnancy that is experiencing vaginal
bleeding and has a suspected diagnosis of placenta previa. The nurse reviews
the physician’s orders and would question which order?
A. Prepare the client for an ultrasound
B. Obtain equipment for external electronic fetal
heart monitoring
C. Obtain equipment for a manual pelvic examination
D. Prepare to draw a Hgb and Hct blood sample
29. An ultrasound is performed on a client at term
gestation that is experiencing moderate vaginal bleeding. The results of the
ultrasound indicate that an abruptio placenta is present. Based on these
findings, the nurse would prepare the client for:
A. Complete bed rest for the remainder of the
pregnancy
B. Delivery of the fetus
C. Strict monitoring of intake and output
D. The need for weekly monitoring of coagulation
studies until the time of delivery
30. A nurse in a labor room is assisting with the
vaginal delivery of a newborn infant. The nurse would monitor the client
closely for the risk of uterine rupture if which of the following occurred?
A. Hypotonic contractions
B. Forceps delivery
C. Schultz delivery
D. Weak bearing down efforts
31. A client is admitted to the birthing suite in
early active labor. The priority nursing intervention on the admission of this
client would be:
A. Auscultating the fetal heart
B. Taking an obstetric history
C. Asking the client when she last ate
D. Ascertaining whether the membranes were ruptured
32. A client who is gravida 1, para 0 is admitted in
labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at
+1 station. The nurse is aware that the fetus’ head is:
A. Not yet engaged
B. Entering the pelvic inlet
C. Below the ischial spines
D. Visible at the vaginal opening
33. After doing Leopold’s maneuvers, the nurse
determines that the fetus is in the ROP position. To best auscultate the fetal
heart tones, the Doppler is placed:
A. Above the umbilicus at the midline
B. Above the umbilicus on the left side
C. Below the umbilicus on the right side
D. Below the umbilicus near the left groin
34. The physician asks the nurse the frequency of a
laboring client’s contractions. The nurse assesses the client’s contractions by
timing from the beginning of one contraction:
A. Until the time it is completely over
B. To the end of a second contraction
C. To the beginning of the next contraction
D. Until the time that the uterus becomes very firm
35. The nurse observes the client’s amniotic fluid and
decides that it appears normal, because it is:
A. Clear and dark amber in color
B. Milky, greenish yellow, containing shreds of mucus
C. Clear, almost colorless, and containing little
white specks
D. Cloudy, greenish-yellow, and containing little
white specks
36. At 38 weeks gestation, a client is having late
decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:
A. Discontinue the catheter, if the reading is not
above 80%
B. Discontinue the catheter, if the reading does not
go below 30%
C. Advance the catheter until the reading is above 90%
and continue monitoring
D. Reposition the catheter, recheck the reading, and
if it is 55%, keep monitoring
37. When examining the fetal monitor strip after the
rupture of the membranes in a laboring client, the nurse notes variable
decelerations in the fetal heart rate. The nurse should:
A. Stop the oxytocin infusion
B. Change the client’s position
C. Prepare for immediate delivery
D. Take the client’s blood pressure
38. When monitoring the fetal heart rate of a client
in labor, the nurse identifies an elevation of 15 beats above the baseline rate
of 135 beats per minute lasting for 15 seconds. This should be documented as:
A. An acceleration
B. An early elevation
C. A sonographic motion
D. A tachycardic heart rate
39. A laboring client complains of low back pain. The
nurse replies that this pain occurs most when the position of the fetus is:
A. Breech
B. Transverse
C. Occiput anterior
D. Occiput posterior
40. The breathing technique that the mother should be
instructed to use as the fetus’ head is crowning is:
A. Blowing
B. Slow chest
C. Shallow
D. Accelerated-decelerated
41. During the period of induction of labor, a client
should be observed carefully for signs of:
A. Severe pain
B. Uterine tetany
C. Hypoglycemia
D. Umbilical cord prolapse
42. A client arrives at the hospital in the second
stage of labor. The fetus’ head is crowning, the client is bearing down, and
the birth appears imminent. The nurse should:
A. Transfer her immediately by stretcher to the
birthing unit
B. Tell her to breathe through her mouth and not to
bear down
C. Instruct the client to pant during contractions and
to breathe through her mouth
D. Support the perineum with the hand to prevent
tearing and tell the client to pant
43. A laboring client is to have a pudendal block. The
nurse plans to tell the client that once the block is working she:
A. Will not feel the episiotomy
B. May lose bladder sensation
C. May lose the ability to push
D. Will no longer feel contractions
44. Which of the following observations indicates
fetal distress?
A. Fetal scalp pH of 7.14
B. Fetal heart rate of 144 beats/minute
C. Acceleration of fetal heart rate with contractions
D. Presence of long-term variability
45. Which of the following fetal positions is most
favorable for birth?
A. Vertex presentation
B. Transverse lie
C. Frank breech presentation
D. Posterior position of the fetal head
46. A laboring
client has external electronic fetal monitoring in place. Which of the
following assessment data can be determined by examining the fetal heart rate
strip produced by the external electronic fetal monitor?
A. Gender of the fetus
B. Fetal position
C. Labor progress
D. Oxygenation
47. A laboring client is in the first stage of labor
and has progressed from 4 to 7 cm in cervical dilation. In which of the
following phases of the first stage does cervical dilation occur most rapidly?
A. Preparatory phase
B. Latent phase
C. Active phase
D. Transition phase
48. A multiparous client who has been in labor for 2
hours states that she feels the urge to move her bowels. How should the nurse
respond?
A. Let the client get up to use the potty
B. Allow the client to use a bedpan
C. Perform a pelvic examination
D. Check the fetal heart rate
49. Labor is a series of events affected by the
coordination of the five essential factors. One of these is the passenger
(fetus). Which are the other four factors?
A. Contractions, passageway, placental position and
function, pattern of care
B. Contractions, maternal response, placental
position, psychological response
C. Passageway, contractions, placental position, and
function, psychological response
D. Passageway, placental position and function,
paternal response, psychological response
50. Fetal presentation refers to which of the
following descriptions?
A. Fetal body part that enters the maternal pelvis
first
B. Relationship of the presenting part to the maternal
pelvis
C. Relationship of the long axis of the fetus to the
long axis of the mother
D. A classification according to the fetal part
51. A client is admitted to the L & D suite at 36
weeks’ gestation. She has a history of C-section and complains of severe
abdominal pain that started less than 1 hour earlier. When the nurse palpates
tetanic contractions, the client again complains of severe pain. After the
client vomits, she states that the pain is better and then passes out. Which is
the probable cause of her signs and symptoms?
A. Hysteria compounded by the flu
B. Placental abruption
C. Uterine rupture
D. Dysfunctional labor
52. Upon completion of a vaginal examination on a
laboring woman, the nurse records 50%, 6 cm, -1. Which 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 achieved passage through the ischial
spines
53. Which of the following findings meets the criteria
of a reassuring FHR pattern?
A. FHR does not change as a result of fetal activity
B. Average baseline rate ranges between 100 – 140 BPM
C. Mild late deceleration patterns occur with some
contractions
D. Variability averages between 6 – 10 BPM
54. Late deceleration patterns are noted when
assessing the monitor tracing of a woman whose labor is being induced with an
infusion of Pitocin. The woman is in a
side-lying position, and her vital signs are stable and fall within a normal
range. Contractions are intense, last 90
seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would
be to:
A. Change the woman’s position
B. Stop the Pitocin
C. Elevate the woman’s legs
D. Administer oxygen via a tight mask at 8 to 10
liters/minute
55. 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
56. Perineal care is an important infection control
measure. When evaluating a postpartum
woman’s perineal care technique, the nurse would recognize the need for further
instruction if the woman:
A. Uses soap and warm water to wash the vulva and
perineum
B. Washes from symphysis pubis back to episiotomy
C. Changes her perineal pad every 2 – 3 hours
D. Uses the peri bottle to rinse upward into her
vagina
57. Which measure would be least effective in
preventing postpartum hemorrhage?
A. Administer Methergine 0.2 mg every 6 hours for 4
doses as ordered
B. Encourage the woman to void every 2 hours
C. Massage the fundus every hour for the first 24
hours following birth
D. Teach the woman the importance of rest and
nutrition to enhance healing
58. When making a visit to the home of a postpartum
woman one week after birth, the nurse should recognize that the woman would
characteristically:
A. Express a strong need to review events and her
behavior during the process of labor and birth
B. Exhibit a reduced attention span, limiting
readiness to learn
C. Vacillate between the desire to have her own
nurturing needs met and the need to take charge of her own care and that of her
newborn
D. Have reestablished her role as a spouse/partner
59. Four hours after a difficult labor and birth, a
primiparous woman refuses to feed her baby, stating that she is too tired and
just wants to sleep. The nurse should:
A. Tell the woman she can rest after she feeds her
baby
B. Recognize this as a behavior of the taking-hold
stage
C. Record the behavior as ineffective maternal-newborn
attachment
D. Take the baby back to the nursery, reassuring the
woman that her rest is a priority at this time
60. Parents can facilitate the adjustment of their
other children to a new baby by:
A. Having the children choose or make a gift to give
to the new baby upon its arrival home
B. Emphasizing activities that keep the new baby and
other children together
C. Having the mother carry the new baby into the home
so she can show the other children the new baby
D. Reducing stress on other the by limiting their
involvement in the care of the new baby
Answers and Rationale
1. Answer: D. The cervix is dilated completely.
The second stage of labor begins when the cervix is
dilated completely and ends with the birth of the neonate.
2. Answer: C. Administer oxygen via face mask.
Late decelerations are due to uteroplacental
insufficiency as the result of decreased blood flow and oxygen to the fetus
during the uterine contractions. This causes hypoxemia; therefore oxygen is
necessary.
Option A: The supine position is avoided because it
decreases uterine blood flow to the fetus. The client should be turned to her
side to displace pressure of the gravid uterus on the inferior vena cava.
Option D: An
intravenous Pitocin infusion is discontinued when a late deceleration is noted.
3. Answer: A. Fetal heart rate of 180 beats per
minute.
A normal fetal heart rate is 120-160 beats per minute.
A count of 180 beats per minute could indicate fetal distress and would warrant
physician notification. By full term, a normal maternal hemoglobin range is
11-13 g/dL as a result of the hemodilution caused by an increase in plasma
volume during pregnancy.
4. Answer: D. Supine position with a wedge under the
right hip. Vena cava and descending aorta compression by the pregnant uterus
impedes blood return from the lower trunk and extremities. This leads to
decreasing cardiac return, cardiac output, and blood flow to the uterus and the
fetus. The best position to prevent this would be side-lying with the uterus
displaced off of abdominal vessels. Positioning for abdominal surgery
necessitates a supine position; however, a wedge placed under the right hip
provides displacement of the uterus.
5. Answer: D. Palpating the maternal radial pulse
while listening to the fetal heart rate.
The nurse simultaneously should palpate the maternal
radial or carotid pulse and auscultate the fetal heart rate to differentiate
the two. If the fetal and maternal heart rates are similar, the nurse may
mistake the maternal heart rate for the fetal heart rate. Leopold’s maneuvers
may help the examiner locate the position of the fetus but will not ensure a
distinction between the two rates.
6. Answer: B. A fetal heart rate of 90 beats per
minute.
A normal fetal heart rate is 120-160 BPM. Bradycardia
or late or variable decelerations indicate fetal distress and the need to
discontinue to Pitocin. The goal of labor augmentation is to achieve three
good-quality contractions in a 10-minute period.
7. Answer: B. Continuous electronic fetal monitoring.
Continuous electronic fetal monitoring should be
implemented during an IV infusion of Pitocin.
8. Answer: D. Notify the physician or nurse midwife.
A normal fetal heart rate is 120-160 beats per minute.
Fetal bradycardia between contractions may indicate the need for immediate
medical management, and the physician or nurse-midwife needs to be notified.
9. Answer: A. Document the findings and tell the
mother that the monitor indicates fetal well-being.
Accelerations are transient increases in the fetal
heart rate that often accompany contractions or are caused by fetal movement.
Episodic accelerations are thought to be a sign of fetal-well being and
adequate oxygen reserve.
10. Answer: B. Assessing the baseline fetal heart
rate.
Assessing the baseline fetal heart rate is important
so that abnormal variations of the baseline rate will be identified if they
occur. Options 1 and 3 are important to assess, but not as the first priority.
11. Answer: A. 1 cm above the ischial spine.
Station is the relationship of the presenting part to
an imaginary line drawn between the ischial spines, is measured in centimeters,
and is noted as a negative number above the line and a positive number below
the line. At -1 station, the fetal presenting part is 1 cm above the ischial
spines.
12. Answer: D. Postpartum infections.
Anemic women have a greater likelihood of cardiac
decompensation during labor, postpartum infection, and poor wound healing.
Anemia does not specifically present a risk for hemorrhage.
13. Answer: D.
Placental separation.
As the placenta separates, it settles downward into
the lower uterine segment. The umbilical cord lengthens, and a sudden trickle
or spurt of blood appears.
14. Answer: B. Increased efficiency of contractions.
Amniotomy can be used to induce labor when the
condition of the cervix is favorable (ripe) or to augment labor if the process
begins to slow. Rupturing of membranes allows the fetal head to contact the
cervix more directly and may increase the efficiency of contractions.
15. Answer: B. Variable decelerations.
Variable decelerations occur if the umbilical cord
becomes compressed, thus reducing blood flow between the placenta and the
fetus.
Option A: Early decelerations result from pressure on
the fetal head during a contraction.
Option C: Late decelerations are an ominous pattern in
labor because it suggests uteroplacental insufficiency during a contraction.
Option D: Short-term variability refers to the
beat-to-beat range in the fetal heart rate.
16. Answer: B. Light stroking of the abdomen to
facilitate relaxation during labor and provide tactile stimulation to the
fetus.
Effleurage is a specific type of cutaneous stimulation
involving light stroking of the abdomen and is used before a transition to
promote relaxation and relieve mild to moderate pain. Effleurage provides
tactile stimulation to the fetus.
17. Answer: B. Fear of losing control.
Pains, helplessness, panicking, and fear of losing
control are possible behaviors in the 2nd stage of labor.
18. Answer: A,
D, B, E, C.
If uterine hypertonicity occurs, the nurse immediately
will intervene to reduce uterine activity and increase fetal oxygenation. The
nurse would stop the Pitocin infusion and increase the rate of the nonadditive
solution, check maternal BP for hyper or hypotension, position the woman in a
side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The
nurse then would attempt to determine the cause of the uterine hypertonicity
and perform a vaginal exam to check for prolapsed cord.
19. Answer: C. Oxytocin (Pitocin) infusion.
Therapeutic management for hypotonic uterine dysfunction
includes oxytocin augmentation and amniotomy to stimulate a labor that slows.
20. Answer: B. Provide pain relief measures.
Management of hypertonic labor depends on the cause.
Relief of pain is the primary intervention to promote a normal labor pattern.
21. Answer: C. Monitoring fetal heart rate.
The priority is to monitor the fetal heart rate.
22. Answer: C. So that each fetal heart rate is
monitored separately.
In a client with a multi-fetal pregnancy, each fetal
heart rate is monitored separately.
23. Answer: D. Hemorrhage.
Because the placenta is implanted in the lower uterine
segment, which does not contain the same intertwining musculature as the fundus
of the uterus, this site is more prone to bleeding.
24. Answer: D. Changes in the shape of the uterus.
Signs of placental separation include lengthening of
the umbilical cord, a sudden gush of dark blood from the introitus (vaginal), a
firmly contracted uterus, and the uterus changing from a discoid (like a disk)
to a globular (like a globe) shape. The client may experience vaginal fullness,
but not severe uterine cramping.
25. Answer: A. Place the client in Trendelenburg’s
position.
When cord prolapse occurs, prompt actions are taken to
relieve cord compression and increase fetal oxygenation. The mother should be
positioned with the hips higher than the head to shift the fetal presenting
part toward the diaphragm. Oxygen at 8
to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
Options B and D: The nurse should push the call light
to summon help, and other staff members should call the physician and notify
the delivery room.
Option C: No attempt should be made to replace the
cord. The examiner, however, may place a gloved hand into the vagina and hold
the presenting part off of the umbilical cord.
26. Answer: A. Swelling of the calf in one leg.
DIC is a state of diffuse clotting in which clotting
factors are consumed, leading to widespread bleeding. Swelling and pain in the calf of one leg are
more likely to be associated with thrombophlebitis.
Options B, C, and D: Platelets are decreased because
they are consumed by the process; coagulation studies show no clot formation
(and are thus normal to prolong); and fibrin plugs may clog the
microvasculature diffusely, rather than in an isolated area. The presence of
petechiae, oozing from injection sites, and hematuria are signs associated with
DIC.
27. Answer: C. Uterine tenderness/pain.
In abruptio placentae, acute abdominal pain is
present. Uterine tenderness and pain accompany placental abruption, especially
with a central abruption and trapped blood behind the placenta. The abdomen
will feel hard and board like on palpation as the blood penetrates the
myometrium and causes uterine irritability. Observation of the fetal monitoring
often reveals increased uterine resting tone, caused by failure of the uterus
to relax in an attempt to constrict blood vessels and control bleeding.
28. Answer: C. Obtain equipment for a manual pelvic
examination.
Manual pelvic examinations are contraindicated when
vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and
Placental previa is ruled out. Digital examination of the cervix can lead to
maternal and fetal hemorrhage.
Option A: A diagnosis of placenta previa is made by
ultrasound.
Option B: External fetal monitoring is crucial in
evaluating the fetus that is at risk for severe hypoxia.
Option D: The H/H levels are monitored, and external
electronic fetal heart rate monitoring is initiated.
29. Answer: B. Delivery of the fetus.
The goal of management in abruptio placentae is to
control the hemorrhage and deliver the fetus as soon as possible. Delivery is
the treatment of choice if the fetus is at term gestation or if the bleeding is
moderate to severe and the mother or fetus is in jeopardy.
30. Answer: B. Forceps delivery.
Excessive fundal pressure, forceps delivery, violent
bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman
at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing
down efforts do not alone add to the risk of rupture because they do not add to
the stress on the uterine wall.
31. Answer: A. Auscultating the fetal heart.
Determining the fetal well-being supersedes all other
measures. If the FHR is absent or persistently decelerating, immediate
intervention is required.
32. Answer: C. Below the ischial spines.
A station of +1 indicates that the fetal head is 1 cm
below the ischial spines.
33. Answer: C. Below the umbilicus on the right side.
Fetal heart tones are best auscultated through the
fetal back; because the position is ROP (right occiput presenting), the back
would be below the umbilicus and on the right side.
34. Answer: C. To the beginning of the next
contraction.
This is the way to determine the frequency of the
contractions
35. Answer: C. Clear, almost colorless, and containing
little white specks.
By 36 weeks gestation, normal amniotic fluid is
colorless with small particles of vernix caseosa present.
36. Answer: D. Reposition the catheter, recheck the
reading, and if it is 55%, keep monitoring.
Adjusting the catheter would be indicated. Normal
fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate
maternal readings.
37. Answer: 2. Change the client’s position.
Variable decelerations usually are seen as a result of
cord compression; a change of position will relieve pressure on the cord.
38. Answer: A. An acceleration.
An acceleration is an abrupt elevation above the
baseline of 15 beats per minute for 15 seconds; if the acceleration persists
for more than 10 minutes it is considered a change in baseline rate. A
tachycardic FHR is above 160 beats per minute.
39. Answer: D. Occiput posterior.
A persistent occiput posterior position causes intense
back pain because of fetal compression of the sacral nerves. Occiput anterior
is the most common fetal position and does not cause back pain.
40. Answer: A. Blowing.
Blowing forcefully through the mouth controls the
strong urge to push and allows for a more controlled birth of the head.
41. Answer: B. Uterine tetany.
Uterine tetany could result from the use of oxytocin
to induce labor. Because oxytocin promotes powerful uterine contractions,
uterine tetany may occur. The oxytocin infusion must be stopped to prevent
uterine rupture and fetal compromise.
42. Answer: D. Support the perineum with the hand to
prevent tearing and tell the client to pant.
Gentle pressure is applied to the baby’s head as it
emerges so it is not born too rapidly. The head is never held back, and it
should be supported as it emerges so there will be no vaginal lacerations. It
is impossible to push and pant at the same time.
43. Answer: A. May lose the ability to push.
A pudendal block provides anesthesia to the perineum.
44. Answer: A. Fetal scalp pH of 7.14.
A fetal scalp pH below 7.25 indicates acidosis and
fetal hypoxia.
45. Answer: A. Vertex presentation.
Vertex presentation (flexion of the fetal head) is the
optimal presentation for passage through the birth canal.
Option B: Transverse lie is an unacceptable fetal
position for vaginal birth and requires a C-section.
Option C: Frank breech presentation, in which the buttocks
present first, can be a difficult vaginal delivery.
Option D: Posterior positioning of the fetal head can
make it difficult for the fetal head to pass under the maternal symphysis
pubis.
46. Answer: D. Oxygenation.
Oxygenation of the fetus may be indirectly assessed
through fetal monitoring by closely examining the fetal heart rate strip.
Accelerations in the fetal heart rate strip indicate good oxygenation, while
decelerations in the fetal heart rate sometimes indicate poor fetal
oxygenation.
47. Answer: C. Active phase.
Cervical dilation occurs more rapidly during the
active phase than any of the previous phases. The active phase is characterized
by cervical dilation that progresses from 4 to 7 cm.
Options A and B: The preparatory, or latent, phase
begins with the onset of regular uterine contractions and ends when rapid
cervical dilation begins.
Option D: Transition is defined as cervical dilation
beginning at 8 cm and lasting until 10 cm or complete dilation.
48. Answer: C. Perform a pelvic examination.
A complaint of rectal pressure usually indicates a low
presenting fetal part, signaling imminent delivery. The nurse should perform a
pelvic examination to assess the dilation of the cervix and station of the
presenting fetal part.
49. Answer: C. Passageway, contractions, placental
position and function, psychological response.
The five essential factors (5 P’s) are passenger
(fetus), passageway (pelvis), powers (contractions), placental position and
function, and psyche (psychological response of the mother).
50. Answer: A. Fetal body part that enters the
maternal pelvis first.
Presentation is the fetal body part that enters the
pelvis first; it’s classified by the presenting part; the three main
presentations are cephalic/occipital, breech, and shoulder.
Option B: The relationship of the presenting fetal
part to the maternal pelvis refers to fetal position.
Option C: The relationship of the long axis to the
fetus to the long axis of the mother refers to fetal lie; the three possible
lies are longitudinal, transverse, and oblique.
51. Answer: C. Uterine rupture.
Uterine rupture is a medical emergency that may occur
before or during labor. Signs and symptoms typically include abdominal pain
that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic
shock, and fetal distress. With placental abruption, the client typically
complains of vaginal bleeding and constant abdominal pain.
52. Answer: A. Fetal presenting part is 1 cm above the
ischial spines.
Station of – 1 indicates that the fetal presenting
part is above the ischial spines and has not yet passed through the pelvic
inlet. A station of zero would indicate that the presenting part has passed
through the inlet and is at the level of the ischial spines or is engaged.
Options B and C: Progress of effacement is referred to
by percentages with 100% indicating full effacement and dilation by centimeters
(cm) with 10 cm indicating full dilation.
Option D: Passage through the ischial spines with
internal rotation would be indicated by a plus station, such as + 1.
53. Answer: D. Variability averages between 6 – 10
BPM.
Variability indicates a well-oxygenated fetus with a functioning
autonomic nervous system.
Option A: FHR should accelerate with fetal movement.
Option B: Baseline range for the FHR is 120 to 160
beats per minute.
Option C: Late deceleration patterns are never
reassuring, though early and mild variable decelerations are expected,
reassuring findings.
54. Answer: B. Stop the Pitocin.
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 Pitocin
infusion since Pitocin is an oxytocin which stimulates the uterus to contract.
Option A: The woman is already in an appropriate
position for uteroplacental perfusion.
Option C: Elevation of her legs would be appropriate
if hypotension were present.
Option D: Oxygen is appropriate but not the immediate
action.
55. Answer: 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.
Option A: Headache is not a side effect since the
spinal fluid is not disturbed by this anesthetic as it would be with a low
spinal (saddle block) anesthesia;
Option B is an effect of epidural anesthesia but is
not the most harmful.
Option C: Respiratory depression is a potentially
serious complication.
56. Answer: D. Uses the peri bottle to rinse upward
into her vagina.
The peri bottle should be used in a backward direction
over the perineum. The flow should never be directed upward into the vagina
since debris would be forced upward into the uterus through the still-open
cervix.
57. Answer: C. Massage the fundus every hour for the
first 24 hours following birth.
The fundus should be massaged only when boggy or soft.
Massaging a firm fundus could cause it to relax.
Options A, B, and D are all effective measures to
enhance and maintain contraction of the uterus and to facilitate healing.
58. Answer: C. Vacillate between the desire to have
her own nurturing needs met and the need to take charge of her own care and
that of her newborn.
One week after birth the woman should exhibit
behaviors characteristic of the taking-hold stage as described in option C.
This stage lasts for as long as 4 to 5 weeks after birth.
Options A and B are characteristic of the taking-in
stage, which lasts for the first few days after birth.
Option D reflects the letting-go stage, which
indicates that psychosocial recovery is complete.
59. Answer: D. Take the baby back to the nursery,
reassuring the woman that her rest is a priority at this time.
Response 1 does not take into consideration the need
for the new mother to be nurtured and have her needs met during the taking-in
stage. The behavior described is typical of this stage and not a reflection of
ineffective attachment unless the behavior persists. Mothers need to
reestablish their own well-being in order to effectively care for their baby.
60. Answer: A. Having the children choose or make a
gift to give to the new baby upon its arrival home.
Special time should be set aside just for the other
children without interruption from the newborn. Someone other than the mother
should carry the baby into the home so she can give full attention to greeting
her other children. Children should be actively involved in the care of the
baby according to their ability without overwhelming them.
Click below to download this question paper
PDF file will be updated soon
Thanks
Visit our sites for more updates
www.thebossacadmy.net for study materials, model previous year
question papers, books & journals.
0 Comments