CH 14-16
The kosher diet followed by many Jewish people forbids the eating of what foods?
1. Pig products and shellfish
2. Dairy products
3. All animal products
4. Dairy products and eggs
1
CH 14
(Explanation: 1. The kosher diet followed by many Jewish people forbids the eating of pig products and shellfish. Certain cuts of meat from sheep and cattle are allowed, as are fish with fins and scales. In addition, many Jews believe that meat and dairy products should not be mixed or eaten at the same meal.)
A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. What should the nurse's response be?
1. "Heparin is used when coagulation problems are resolved."
2. "Heparin is safer because it does not cross the placenta."
3. "They are the same drug, but heparin is less expensive."
4. "Coumadin interferes with iron absorption in the intestines."
2
(Explanation: 2. Heparin is safest for the client to take because it does not cross the placental barrier.)
A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity?
1. Patellar reflexes weak or absent
2. Increased appetite
3. Respiratory rate of 16
4. Fetal heart rate of 120
1
(Explanation: 1. Early signs of magnesium sulfate toxicity are related to a decrease in deep tendon reflexes.)
What is one of the most common initial signs of nonreassuring fetal status?
1. Meconium-stained amniotic fluid
2. Cyanosis
3. Dehydration
4. Arrest of descent
1
(Explanation: 1. The most common initial signs of nonreassuring fetal status are meconium-stained amniotic fluid and changes in the fetal heart rate (FHR).)
After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following?
1. Breech presentation
2. Uteroplacental insufficiency
3. Compression of the fetal head
4. Umbilical cord compression
4
(Explanation: 4. Variable decelerations occur when there is umbilical cord compression.)
A 26-year-old client is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes?
1. A 50g, 1-hour glucose screening test
2. A single fasting glucose level
3. A 100g, 1-hour glucose tolerance test
4. A 100g, 3-hour glucose tolerance test
4
(Explanation: 4. Gestational diabetes is diagnosed if two or more of the following values are met or exceeded after taking the 100 g, 3-hour OGTT: Fasting: 95 mg/dL; 1 hour: 180 mg/dL; 2 hours: 155 mg/dL; 3 hours: 140 mg/dL.)
A 26-year-old client is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client?
1. "Exercise either just before meals or wait until 2 hours after a meal."
2. "Carry hard candy (or other simple sugar) when exercising."
3. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate."
4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk."
2
(Explanation: 2. The nurse should advise her to carry a simple sugar such as hard candy because of the possibility of exercise-induced hypoglycemia.)
The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?
1. "I need to get RhoGAM so I don't have problems with my next pregnancy."
2. "Because my baby is Rh-positive, I don't need RhoGAM."
3. "If my baby had the same blood type I do, it might cause complications."
4. "Before my next pregnancy, I will need to have a RhoGAM shot."
1
(Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization.)
If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist?
1. Call a second physician to assist.
2. Prepare for an immediate cesarean delivery.
3. Assist the woman into McRoberts maneuver.
4. Utilize fundal pressure to push the fetus out.
3
(Explanation: 3. The McRoberts maneuver is thought to change the maternal pelvic angle and therefore reduce the force needed to extract the shoulders, thereby decreasing the incidence of brachial plexus stretching and clavicular fracture.)
During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client's partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following?
Select all that apply.
1. Uterine contraction pattern
2. Fetal position
3. Presence of the mucous plug
4. Cervical dilation and effacement
5. Presenting part
4, 5
(Explanation: 4. The vaginal examination of a laboring client obtains information about the station of the presenting part and the dilation and effacement of the cervix.
5. The vaginal examination of a laboring client obtains information about the fetal presenting part.)
Which of the following is the most prevalent medical complication of pregnant adolescents?
1. Constipation
2. Preeclampsia-eclampsia
3. Heartburn
4. Rapid enlargement and sensitivity of breasts
Answer: 2
Explanation: 2. Preeclampsia-eclampsia is the most prevalent medical complication of pregnant adolescents and is typically characterized by high blood pressure, proteinuria, and edema.
The client at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The client's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the client?
1. "Your low iron intake has caused anemia, which leads to the neural tube defect."
2. "You should increase your vitamin C intake to improve your anemia."
3. "You are too picky about food. Your poor diet caused your baby's defect."
4. "You haven't had enough folic acid in your diet. You should take a supplement."
4
(Explanation: 4. An inadequate intake of folic acid has been associated with neural tube defects (NTDs) (e.g., spina bifida, anencephaly, meningomyelocele) in the fetus or newborn.)
A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response?
1. "This medication will halt the labor process until the baby is more mature."
2. "This medication will relax the smooth muscles in the infant's lungs so the baby can breathe."
3. "This medication is effective in stimulating lung development in the preterm infant."
4. "This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor."
3
(Explanation: 3. Betamethasone or dexamethasone is often administered to the woman whose fetus has an immature lung profile to promote fetal lung maturation.)
During labor, the fetus was in a brow presentation, but after a prolonged labor, the fetus converted to face presentation and was delivered vaginally with forceps assist. What should the nurse explain to the parents?
1. The infant will need to be observed for meconium aspiration.
2. Facial edema and head molding will subside in a few days.
3. The infant will be given prophylactic antibiotics.
4. Breastfeeding will need to be delayed for a day or two.
2
(Explanation: 2. Any facial edema and head molding that result from the use of forceps at birth will subside in a few days.)
A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately?
1. Change the client's position in bed.
2. Notify the physician that birth is imminent.
3. Administer oxygen at 2 liters per minute.
4. Begin continuous fetal heart rate monitoring.
4
(Explanation: 4. Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.)
A client at 37 weeks' gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates three contractions in 10 minutes, no decelerations, and accelerations four times in 1 hour. What would this test be considered?
A. Positive nonstress test
B. Negative contraction stress test
C. Positive contraction stress test
D. Negative nonstress test
B. Negative contraction stress test
CH 16
The nurse has written the nursing diagnosis Injury, Risk for for a diabetic pregnant client. Interventions for this diagnosis include which of the following?
SATA.
1. Assessment of fetal heart tones
2. Perform oxytocin challenge test, if ordered
3. Refer the client to a diabetes support group
4. Assist with the biophysical profile assessment
5. Develop an appropriate teaching plan
1, 2, 4
(Explanation: 1. Reassuring fetal heart rate variability and accelerations are interpreted as adequate placental oxygenation.
2. The nurse would perform oxytocin challenge test (OCT)/contraction stress test (CST) and non-stress tests as determined by physician.
4. The nurse assists the physician in performing a biophysical profile assessment.)
The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician?
1. Excretion of less than 300 mg of protein in a 24-hour period
2. Platelet count of less than 100,000/mm3
3. Urine output of 50 mL per hour
4. 12 respirations
2
(Explanation: 2. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 100,000/mm3).)
Five clients are in active labor in the labor unit. Which women should the nurse monitor carefully for the potential of uterine rupture?
1. Age 15, in active labor
2. Age 22, with eclampsia
3. Age 25, last delivery by cesarean section
4. Age 32, first baby died during labor
5. Age 27, last delivery 11 months ago
3, 5
(Explanation: 3. A woman who has had a previous cesarean section is at risk for uterine rupture.
5. A woman who does not have at least 18 months between deliveries is at greater risk for uterine rupture.)
The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention?
1. Early decelerations with each contraction
2. Variable decelerations that recover to the baseline
3. Late decelerations with minimal variability
4. Accelerations
3
(Explanation: 3. Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention.)
The nurse is preparing to conduct a nonstress test with a pregnant patient. In which order should the nurse complete the steps of the procedure?
1. Obtain baseline measurement for 20 minutes
2. Place the patient in the semi-Fowler's position
3. Place the pressure transducer over the uterine fundus
4. Give the patient a handheld marker to indicate when fetal movement is felt
5. Place the ultrasound transducer from the external fetal monitor over the FHR
2, 5, 3, 1, 4
CH 16
A diabetic client goes into labor at 36 weeks' gestation. Provided that tests for fetal lung maturity are successful, the nurse will anticipate which of the following interventions?
SATA.
1. Administration of tocolytic therapy
2. Beta-sympathomimetic administration
3. Allowance of labor to progress
4. Hourly blood glucose monitoring
5. Cesarean birth may be indicated if evidence of reassuring fetal status exists
3, 4
(Explanation: 3. There will be no attempt to stop the labor, as this can compromise the mother and fetus.
4. To reduce incidence of congenital anomalies and other problems in the newborn, the woman should be euglycemic (have normal blood glucose) throughout the pregnancy.)
The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include which of the following?
SATA.
1. Prematurity
2. Maternal intrapartum fever
3. Membranes ruptured for longer than 18 hours
4. A previously infected infant with GBS disease
5. An older mother having her first baby
1, 2, 3, 4
(Explanation: 1. Prematurity is a risk factor.
2. Maternal intrapartum fever is a risk factor.
3. Prolonged rupture of membranes is a risk factor.
4. A previously infected infant increases the risk.)
During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following?
SATA.
1. Intravenous access
2. Cesarean delivery
3. Immediate vaginal delivery
4. McRoberts maneuver
5. A crash cart
1, 2, 5
(Explanation: 1. When an amniotic fluid embolism is suspected, intravenous access is obtained as quickly as possible.
2. Shortness of breath, cyanosis, and hypoxia are symptoms of an amniotic fluid embolus, which necessitates immediate cesarean delivery.
5. The chances of a code are high, so the crash cart needs to be available.)
The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following?
Select all that apply.
1. Maternal dehydration
2. Maternal hyperthyroidism
3. Fetal hypoxia
4. Prematurity
5. Anesthesia or regional analgesia
1, 2, 3, 4
(Explanation: 1. Maternal dehydration can cause fetal tachycardia.
2. Maternal hyperthyroidism can cause fetal tachycardia.
3. Fetal tachycardia can indicate fetal hypoxia.
4. Prematurity can cause fetal tachycardia.)