Ante partum
A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sign. The nurse determines this sign indicates:
1.A softening of the cervix
2.A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.
3.The presence of hCG in the urine
4.The presence of fetal movement
1. In the early weeks of pregnancy the cervix becomes softer as a result of increased vascularity and hyperplasia, which causes the Goodell's sign
A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant client to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term?
1."It is the irregular, painless contractions that occur throughout pregnancy."
2."It is the soft blowing sound that can be heard when the uterus is auscultated."
3."It is the fetal movement that is felt by the mother."
4."It is the thinning of the lower uterine segment."
3. Quickening is fetal movement and may occur as early as the 16th and 18th week of gestation, and the mother first notices subtle fetal movements that gradually increase in intensity. Braxton Hicks contractions are irregular, painless contractions that may occur throughout the pregnancy. A thinning of the lower uterine segment occurs about the 6th week of pregnancy and is called Hegar's sign.
The slight overlapping of cranial bones or shaping of the fetal head during labor is called:
a. Lightening.
b. Molding.
c. Ferguson reflex.
d. Valsalva maneuver.
B. Molding
(Fetal head formation is called molding. Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mother's sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor.)
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to:
A. Change the woman's position
B. Notify the care provider
C. Assist with amnioinfusion
D. Insert a scalp electrode
A. Correct: Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava.
B. Incorrect: If the fetus does not respond to primary nursing interventions for late decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider.
C. Incorrect: An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The fetal heart rate pattern associated with this situation most likely reveals variable deceleration.
D. Incorrect: A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurse's first priority.
A primigravid client is 39 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit?
1. Nausea
2. Dysuria
3. Urinary frequency
4. Intermittent diarrhea
. Urinary frequency
Urinary frequency recurs at the end of the third trimester. As the uterus enlarges, it again compresses the bladder, causing urinary frequency
A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2005. Using Nagele's rule, the nurse determines the estimated date of confinement as:
1.July 26, 2006
2.June 12, 2007
3.June 26, 2005
4.July 12, 2007
3. Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period, subtract three months, and then add one year to that date.
A gravid woman and her husband inform the nurse that they have purchased a three-story home that was built in the 1930's. It is critical that the nurse counsel the couple that before moving into the home they do which of the following?
1. Remove all old carpeting
2. Check the water for heavy metals
3. Replace ll copper pipes
4. Monitor the bathrooms for signs of mildew
2. Check the water for heavy metals
The water should be checked for lead. Lead consumption by the woman during pregnancy and/or by the baby can result in permanent central nervous system damage in the child
To care for a laboring woman adequately, the nurse understands that the __________ stage of labor varies the most in length?
a. First
b. Third
c. Second
d. Fourth
To care for a laboring woman adequately, the nurse understands that the __________ stage of labor varies the most in length?
a. First
b. Third
c. Second
d. Fourth
A
(The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.)
Fetal bradycardia is most common during:
A. Intraamniotic infection
B. Fetal anemia
C. Prolonged umbilical cord compression
D. Tocolytic treatment using ritodrine
C
A. Incorrect: This circumstance most likely would result in fetal tachycardia.
B. Incorrect: This circumstance most likely would result in fetal tachycardia.
C. Correct: Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension.
D. Incorrect: This circumstance most likely would result in fetal tachycardia.
The nurse providing care for the laboring woman should understand that accelerations with fetal movement:
A. Are reassuring
B. Are caused by umbilical cord compression
C. Warrant close observation
D. Are caused by uteroplacental insufficiency
A. Correct: Episodic accelerations in the FHR occur during fetal movement and are indications of fetal well-being.
B. Incorrect: Umbilical cord compression results in variable decelerations in the FHR.
C. Incorrect: Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation.
D. Incorrect: Uteroplacental insufficiency would result in late decelerations in the FHR.
During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal heart rate is normal if which of the following is noted?
1.80 BPM
2.100 BPM
3.150 BPM
4.180 BPM
3. The fetal heart rate depends in gestational age and ranges from 160-170 BPM in the first trimester but slows with fetal growth to 120-160 BPM near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 BPM with the uterus at rest, the fetus may be in distress.
A client is at 8 weeks gestation. Which of the following findings would the nurse expect to see?
1. Multiple pillow orthopnea
2. Maternal ambivalence
3. Fundus at the umbilicus
2. Maternal ambivalence
Ambivalence is a common finding of women during the first trimester
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?
1.Encourage the mother to breastfed soon after birth
2. Support the mother in her reaction to the newborn infant
3.Tell the mother that it is important to hold the newborn infant.
4. document a complete account of the mother's reaction on the birth record.
2. Support the mother in her reaction to the newborn infant
Fetal tachycardia is most common during:
A. Maternal fever
B. Umbilical cord prolapse
C. Regional anesthesia
D. MgSO4 administration
A. Maternal fever
Correct: Fetal tachycardia can be considered an early sign of fetal hypoxemia and can also result from maternal or fetal infection.
B. Umbilical cord prolapse
Incorrect: This situation most likely would result in fetal bradycardia, not tachycardia.
C. Regional anesthesia
Incorrect: This situation most likely would result in fetal bradycardia, not tachycardia.
D. MgSO4 administration
Incorrect: This situation most likely would result in fetal bradycardia, not tachycardia.
p. 505
The nurse providing care for the laboring woman should understand that variable FHR decelerations are caused by:
A. Altered fetal cerebral blood flow
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal hypoxemia
B
A. Incorrect: Altered fetal cerebral blood flow would result in early decelerations in the FHR.
B. Correct: Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord.
C. Incorrect: Uteroplacental insufficiency would result in late decelerations in the FHR.
D. Incorrect: Fetal hypoxemia would result in tachycardia initially, then bradycardia if hypoxia continues.
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as:
1.G = 3, T = 2, P = 0, A = 0, L =1
2.G = 2, T = 0, P = 1, A = 0, L =1
3.G = 1, T = 1. P = 1, A = 0, L = 1
4.G = 2, T = 0, P = 0, A = 0, L = 1
2. Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies. T is term births, the number born at term (38-41 weeks). P is preterm births, the number born before 38 weeks gestation. A is abortions or miscarriages (included in gravida if before 20 weeks gestation; included in parity if past 20 weeks gestation). L is live births, the number of live births or living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.
The result of a pregnant woman's glucose challenge test is 145 mg/dL. Which of the following information is appropriate for the nurse to give the client at this time?
1. "You will need to inject insulin at least once a day for the rest of the pregnancy"
2. "Daily oral medicines will be prescribed for you to take"
3. "You need to have a fasting glucose tolerance test as soon as possible"
4. "The results are within normal limits so no intervention is needed"
3. "You need to have a fasting glucose tolerance test as soon as possible"
The nurse has received report regarding her patient in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and ?2-2. The nurse's interpretation of this assessment is that:
a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines.
b. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines.
c. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines.
d. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.
(The correct description of the vaginal examination for this woman in labor is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below).)
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?
1. Administer oxygen via face mask
2. Place the mother in a supine position
3. Increase the rate of the oxytocin intravenous infusion
4. Document the findings and continue to monitor the fetal patterns
1. Administer oxygen via face mask
Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.
A nurse is working in the prenatal clinic. Which of the following findings would the nurse consider to be within normal limits for a client in the third trimester of pregnancy?
1. Diplopia
2. Epistaxis
3. Bradycardia
4. Oliguria
2. Epistaxis
Epistaxis is commonly seen in pregnant clients. The bleeding is related to the increased vascularity of the mucous membranes. Unless the blood loss is significant, it is a normal finding.
A nurse is performing an assessment of a primapira who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing?
1.Consistent increase in fundal height
2.Fetal heart rate of 180 BPM
3.Braxton hicks contractions
4.Quickening
2. The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160-170 BPM in the first trimester and slows with fetal growth, near and at term, the fetal heart rate ranges from 120-160 BPM. The other options are expected.
toward the right side of the mother's back. Which of the following is consistent with this assessment?
1. ROA, -2 station
2. RSP, -2 station
3. RMA, +2 station
4. ROP, +2 station
4. ROP, +2 station
ROP = Right occipital posterior (the back of the baby's head is facing toward the mother's right posterior), and +2 Station - the presenting part is 2 cm below the ischial spines
Incorrect
ROA = Right occipital anterior (the back of the babay's head is facing toward the mother's right anterior). -2 Station - the presenting part is 2 cm above the inschial spines
Incorrect
RSP = Risht sacral posterior (the buttocks of the baby are facing towards the mother's right posterior). -2 Station - the presenting part is 2 cm above the ischial spines
Incorrect
RMA = Right mentum anterior (the face of the baby is facing toward the mother's right anterior). +2 Station - presenting part is 2 cm below the ischial spines
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
1. The contractions are regular.
2. The membranes have ruptured
3. The cervix is completely dilated
4. The client starts to expel clear vaginal fluid
3. The cervix is completely dilated
The nurse caring for the laboring woman should understand that early decelerations are caused by:
A. Altered fetal cerebral blood flow
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Spontaneous rupture of membranes
A. Correct: Early decelerations are the fetus's response to fetal head compression.
B. Incorrect: Variable decelerations are associated with umbilical cord compression.
C. Incorrect: Late decelerations are associated with uteroplacental insufficiency.
D. Incorrect: Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.
A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurse's answer is based on the knowledge that the anterior fontanel closes after birth by _____ months.
a. 2
b. 12
c. 8
d. 18
D
(The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.)