Intrap-artum
A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes?
“What is provide supplemental oxygen”
Rationale: The nurse should provide supplemental oxygen if a client who has been administered combined spinal–epidural analgesia exhibits signs of hypotension and associated FHR changes. The client should be assisted to a semi-Fowler position; the client should not be kept in a supine position or be turned on her left side.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 14: Nursing Management During Labor and Birth, p. 509.
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. What action should the nurse prioritize?
"What is check when the pt for the last voided"
Rationale: The most probable explanation of the mass is a full bladder. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 14: Nursing Management During Labor and Birth, p. 517.
A client has been admitted to the hospital with a diagnosis of severe preeclampsia. What nursing interventions is the priority?
"What is confine the client to bed rest in a darkened room"
Rationale: With severe preeclampsia, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because bright light can also trigger seizures.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications, p. 712.
In order to advocate for children and families, the nurse must first acknowledge that the basic system in which health behavior and care are organized, secured, and performed is the:
"What is family"
Rationale: The family is the basic system in which health behavior and care are organized, secured, and performed. In most families, the parents or guardians, as advocates for their child, provide health promotion and health prevention care, as well as primary management of care when the child is sick. Parents and guardians have the prime responsibility for initiating and coordinating services rendered by health professionals.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 1: Perspectives on Maternal and Child Health Care, p. 17.
The nurse is instructing on maternal hormones which may impact the onset of labor. What hormones are included in the discussion?
"What are oxytocin, progesterone, and prostaglandins"
Rationale: There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 13: Labor and Birth Process, p. 456.
A nurse is caring for a client who is receiving oxytocin for induction of labor. The patient has an intrauterine pressure catheter place to monitor uterine contractions. What contraction pattern should the nurse discontinue the infusion of oxytocin?
“What is uterine tachysystole”
Rationale: Uterine tachysystole is when the contraction is longer than 90 seconds and should be stopped due to the risk of a non-reassuring heart rate from the baby. Possibly due to cord compression, or head compression
The five "Ps" of labor are__
“What is passageway, passenger, position, powers, psychological”
Rationale: The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 13: Labor and Birth Process, p. 458.
A nurse is assessing a client at 35 weeks gestation who is receiving mag sulfate via continuous IV infusion for severe pre-eclampsia. What elimination finding should the nurse report to the provider?
"What is urine output of 20ml"
Rationale: This can indicate inadequate renal perfusion, increasing the risk of mag sulfate toxicity
The home care nurse is providing care and education to a client who is pregnant for the first time. The client states, “I have no money or food. I don't know what I should do. I want to provide for my unborn child.” The nurse refers the woman to the WIC program and a local food bank. This is an example of what aspect of community-based nursing?
"What is planning"
Rationale: Planning and intervention focus on using individual, family, and community resources to assist in restoring a client's health to maximum possible functioning while continuing to monitor for possible side effects or complications to treatment.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 1: Perspectives on Maternal and Child Health Care, p. 17.
What procedure is contraindicated in an intrapartum client with bright red, painless bleeding?
“What is a vaginal exam”
Rationale: A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out.
An OB/GYN care provider has just finished evaluating the 100th client. If the nurse could review all the documentation from each client related thus far, which type of pelvis would the nurse predict as being identified most often by the care provider as supporting the success of a vaginal delivery?
"What is gynecoid and anthropoid, respectively"
Rationale: The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid inlet allows the fetus room to pass through the dimensions of the bony passageway. The anthropoid pelvis is elongated in its dimensions. The anterior–posterior diameter is roomy, but the transverse diameter is narrow compared with that of the gynecoid pelvis. This type of pelvis can prevent a vaginal delivery in some women.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 13: Labor and Birth Process, p. 460.
At what point should the nurse document the end of the third stage of labor?
“What is the delivery of the placenta?”
Rationale: The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record.
Bleeding gums, oozing IV site, and petechia are some signs of DIC. This blood test can confirm this diagnosis.
"What is fibrinogen levels"—
Rationale: typically are increased in pregnancy (hyperfibrinogenemia); thus, a moderate dip in fibrinogen levels might suggest DIC and, if profuse bleeding occurs, the clotting cascade might be compromised
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications, p.703
Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of what function of the family?
“What is socialization”
Rationale: Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback, and guides problem-solving. Incorporating religious beliefs, values, and attitudes is an example of socialization.
(Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 44: Nursing Care of the Child With an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder, p. 1695).
The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate?
“What is palpating the ischial spines.”
Rationale: Station is determined by creating an imaginary line between the ischial spines. The descent of the presenting part of the fetus is then compared with the level of that “line.”
When reviewing the laboratory test results of a client in labor. What would the nurse see an increase in?
“What is an increase in white blood cells”
Rationale: The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 13: Labor and Birth Process, p. 473.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?
"What is the transition phase"
Rationale: The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the transition phase is 8 to 10 cm.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 13: Labor and Birth Process, p. 475.
The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The expected finding for an infant will include__?
"What is softening of the nail beds"
Rationale: Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends.
Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 41: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder, p. 1533.
A nurse is completing a family assessment on a routine home health visit. The parents have a child with a severe peanut allergy. The mother states that she does not purchase any foods with peanut or peanut oil for her family. The other children are allowed to have foods containing peanuts while they are at school and visiting with friends and family. The nurse would conclude that which theories would most likely be the basis for this family's functioning?
“What is the Adaptation Theory?”
Rationale: Adaptation theory is based on an understanding of humans and their interaction with the environment. In this situation, the mother is manipulating the physical environment for the child with allergies, as well as the needs and/or desires of the other children
Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 2: Theory, Research, and Evidence-Based Practice, pp. 27, 40).
The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to what event?
“What is uteroplacental insufficiency”
Rationale: Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health
The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on___
“What is a pH of 6.5”
Rationale: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 14: Nursing Management During Labor and Birth, p. 487.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?
"What is +4"
Rationale: As the fetus is being born, the fetus is at +4 station
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 13: Labor and Birth Process, p. 456
A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. What intervention should the nurse first take?
"What is turn the patient onto her left side"
Rationale: The nurse should turn the patient onto her left side since late decelerations indicate uteroplacental insufficiency. The patient may be experiencing pressure on the inferior vena cava.
A nurse is observing interactions between a new mother and her newborn. The nurse observes the mother not responding to her newborn's cries. Which of Erik Erikson's growth and development theories does the nurse understand the mother is not addressing?
"What is Erik Erikson's Trust vs Mistrust stage"
Rationale: Erikson's Trust vs Mistrust stage is when the infant learns to rely on basic needs, such as warmth, food, and comfort. The mother in this scenario is not meeting these basic needs.
Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 21: Development Concepts, pg 516.
A nurse is caring for a client who is 42 weeks gestation and is having an ultrasound. What condition would require an amnioinfusion?
“What is oligohydramnios”
Rationale: Oligohydramnios is an indication for an amnioinfusion because not enough amniotic fluid may cause IUGR, restrict fetal movement, or cause fetal distress during labor.