Chapter 7
A client with preeclampsia is being monitored. Which of the following findings indicates that the client's condition may be worsening?
A. Decreased BP
B. Decreased proteinuria
C. Increased Edema
D. Increased fetal movement
C. Increased Edema
A nurse is monitoring a client in labor. Which of the following findings indicates the transition phase of labor?
A. Cervical dilation of 4-7 cm
B. Intense contractions lasting 60-90 seconds
C. Fetal descent in the bith canal
D. Moderate effacement of the cervix
B. Intense contractions lasting 60-90 seconds
The nurse is assessing a fetal heart rate strip and notes the presence of decelerations. What is the priority nursing action for variable decelerations?
A) Administer tocolytics
B) Change the maternal position
C) Prepare for an emergency cesarean section
D) Increase the intravenous fluid rate
B) Change the maternal position
Which clinical intervention is the only known cure for preeclampsia?
A. Magnesium Sulfate
B. Delivery of the fetus
C. Antihypertensive medications
D. Administration of aspirin (ASA) every day of the pregnancy
B - Delivery of the fetus
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
A. Hypoglycemia
B. Hypercalcemia
C. Hyperinsulinemia
D. Hypobilirubinemia
A. Hypoglycemia
A nurse is teaching a client about the signs of preterm labor. Which of the following should the nurse include in the teaching?
A. Regular contractions every 10 minutes
B. Occasional back pain
C. Increased fetal movement
D. Mild pelvic pressure
A. Regular contractions every 10 minutes
During which stage of labor does the nurse expect to assess the greatest frequency of contractions?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
A. First stage
A fetal heart rate pattern shows an abrupt decrease in FHR that lasts less than 30 seconds. This pattern is classified as:
A) Early deceleration
B) Late deceleration
C) Variable deceleration
D) Prolonged deceleration
C) Variable deceleration
The clinic nurse is performing a prenatal assessment on a pregnant patient at risk for preeclampsia. Which clinical sign would not present as a symptom of preeclampsia?
A. Edema
B. Proteinuria
C. Glucosuria
D. Hypertension
C - glucosuria
A lab finding indicative of DIC is one that shows
A. decreased fibrinogens
B. increased platelets
C. increased hematocrit
D. decreased thromboplastin time
A. decreased fibrinogens
A woman at 28 weeks of gestation is diagnosed with placenta previa. What is the most appropriate nursing intervention?
A. Encourage ambulation to promote circulation
B. Monitor the fetal heart rate continuously
C. Prepare the client for immediate delivery
D. Educate the client on vaginal delivery options
B. Monitor the fetal heart rate continuously
During labor, the nurse notes variable decelerations in the fetal heart rate. What is the priority nursing intervention?
A. Position client in left lateral position
B. Prepare for immediate delivery
C. Reassess the fetal heart rate in 15 minutes
D. Administer oxygen to the mother through nose
A. Position client in left lateral position
A nurse is teaching a group of students about fetal heart rate assessments. Which statement by a student indicates a need for further teaching?
A) "Fetal heart rate should be assessed for a full minute."
B) "Variability in the fetal heart rate is always abnormal."
C) "Decelerations can indicate a change in fetal oxygenation."
D) "Baseline fetal heart rate is the average rate over a 10-minute period."
B) Variability in the Fetal heart rate is always abnormal
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
A. Abdominal palpation
B. Venous sample of blood
C. Checking DTR
D. Auscultation of the heart and lungs.
A. Abdominal palpation
A. Gastrointestinal upset
B. effects of mag sulfate
C. anxiety caused by hospitilization
D. worsening disease and impending convulsion
D. Worsening disease and impending convulsion
A nurse discusses the risks associated with multiple gestation with a pregnant client. Which complication should the nurse highlight? (sata)
A. Increased risk of gestational diabetes
B. Decreased risk of preeclampsia
C. Lower likelihood of cesarean delivery
D. Increased risk of PTL
A - Increased risk of gestational diabetes
B - Decreased risk of preeclampsia
D. Increased risk of PTL
A nurse is teaching a client about the stages of labor. Which statement by the client indicates a correct understanding?
A) "The second stage ends when the baby is delivered."
B) "The first stage is the shortest stage of labor."
C) "The third stage involves the expulsion of the placenta."
D) "The fourth stage is when the cervix dilates to 10 cm."
C - The third stage involves the expulsion of the placenta
A nurse notes that the fetal heart rate is consistently above 160 bpm. What is the term for this condition?
A) Bradycardia
B) Tachycardia
C) Normal variability
D) Sinusoidal pattern
B) Tachycardia
Which maternal condition always necessitates delivery by cesarean birth?
A. Partial abruptio placentae
B. Total placenta previa
C. Ectopic pregnancy
D. Eclampsia
B. Total placenta previa
Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?
A. Determining cervical dilation and effacement
B. Monitoring FHR and maternal VS
C. Observing vaginal bleeding or leakage of amniotic fluid
D. Determining frequency, duration and intensity of contractions
A. Determining cervical dilation and effacement
A pregnant client reports severe headaches, visual disturbances, and elevated blood pressure. What condition should the nurse suspect?
A. Gestational Diabetes
B. Preeclampsia
C. Ectopic pregnancy
D. Oligohydramnios
B. Preeclampsia
During the third stage of labor, the nurse observes signs of placental separation. Which of the following indicates that the placenta is separating?
A) Lengthening of the umbilical cord
B) Maternal urge to push
C) Sudden increase in maternal pain
D) Fetal heart rate acceleration
A) lengthening of the umbilical cord
After assessing a fetal heart rate strip, the nurse identifies late decelerations. What is the most appropriate nursing intervention?
A) Encourage the client to push during contractions
B) Administer oxygen to the mother
C) Place the client in a supine position
D) Increase IV fluids
B) Administer oxygen to the mother
A. Bradycardia
B. Hard boardlike abdomen
C. Decrease in fundal height
D. Decrease in abdominal pain
B. Hard boardlike abdomen
The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? SATA
A. Cool, clammy skin
B. Altered sensorium
C. Pulse ox reading pf 95%
D. RR of less than 12 breaths/min
E. Absence of DTR
B - Altered sensorium
D - RR less than 12
E - Absence of DTR