NUR 1140 Ricci Chapter 21 - Test Bank - 4th Edition
Questions with 100% Verified Answers Latest Update
Question: 1. After spontaneous rupture of membranes, the nurse notices a prolapsed cord.
The nurse immediately places the woman in which position?
A. supine
B. side-lying
C. sitting
D. knee-chest
Answer:
Answer: D Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would
position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine,
side-lying, or sitting would not provide relief of cord compression.
Question: 2. A primigravida whose labor was initially progressing normally is now
experiencing a decrease in the frequency and intensity of her contractions. The nurse would
assess the woman for which condition?
A. a low-lying placenta
B. fetopelvic disproportion
C. contraction ring
D. uterine bleeding
Answer:
Answer: B Rationale: The woman is experiencing dystocia most likely due to hypotonic
uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying
placenta, contraction ring, or uterine bleeding would not be associated with a change in
labor pattern.
Question: 3. Which assessment finding will alert the nurse to be on the lookout for possible
placental abruption during labor?
A. macrosomia
B. gestational hypertension
C. gestational diabetes
D. low parity
Answer:
Answer: B Rationale: Risk factors for placental abruption include preeclampsia, gestational
hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation
defects, previous history of abruption, intimate partner violence, and placental pathology.
Macrosomia, gestational diabetes, and low parity are not considered risk factors.
Question: 4. A woman in labor is experiencing hypotonic uterine dysfunction. Assessment
reveals no fetopelvic disproportion. Which group of medications would the nurse expect to
administer?
A. sedatives
B. tocolytics
, C. uterine stimulants
D. corticosteroids
Answer:
Answer: C Rationale: For hypotonic labor, a uterine stimulant such as oxytocin may be
prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the
woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics
would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal
lung maturity for women experiencing preterm labor.
Question: 5. A woman gave birth to a newborn via vaginal birth with the use of a vacuum
extractor. The nurse would be alert for which possible effect in the newborn?
A. asphyxia
B. clavicular fracture
C. cephalhematoma
D. central nervous system injury
Answer:
Answer: C Rationale: Use of forceps or a vacuum extractor poses the risk of tissue trauma,
such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and
caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated
with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia.
Central nervous system injury is not associated with the use of a vacuum extractor.
Question: 6. A pregnant client undergoing labor induction is receiving an oxytocin infusion.
Which finding would require immediate intervention?
A. fetal heart rate of 150 beats/minute
B. contractions every 2 minutes, lasting 45 seconds
C. uterine resting tone of 14 mm Hg
D. urine output of 20 mL/hour
Answer:
Answer: D Rationale: Oxytocin can lead to water intoxication. Therefore, a urine output of
20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150
beats/minute is within the accepted range of 120 to 160 beats/minute. Contractions should
occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20
mm Hg would require intervention.
Question: 7. A woman with a history of crack cocaine use disorder is admitted to the labor
and birth area. While caring for the client, the nurse notes a sudden onset of fetal
bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also
reports acute abdominal pain that is continuous. Which condition would the nurse suspect?
A. amniotic fluid embolism
B. shoulder dystocia
C. uterine rupture
D. umbilical cord prolapse
Questions with 100% Verified Answers Latest Update
Question: 1. After spontaneous rupture of membranes, the nurse notices a prolapsed cord.
The nurse immediately places the woman in which position?
A. supine
B. side-lying
C. sitting
D. knee-chest
Answer:
Answer: D Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would
position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine,
side-lying, or sitting would not provide relief of cord compression.
Question: 2. A primigravida whose labor was initially progressing normally is now
experiencing a decrease in the frequency and intensity of her contractions. The nurse would
assess the woman for which condition?
A. a low-lying placenta
B. fetopelvic disproportion
C. contraction ring
D. uterine bleeding
Answer:
Answer: B Rationale: The woman is experiencing dystocia most likely due to hypotonic
uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying
placenta, contraction ring, or uterine bleeding would not be associated with a change in
labor pattern.
Question: 3. Which assessment finding will alert the nurse to be on the lookout for possible
placental abruption during labor?
A. macrosomia
B. gestational hypertension
C. gestational diabetes
D. low parity
Answer:
Answer: B Rationale: Risk factors for placental abruption include preeclampsia, gestational
hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation
defects, previous history of abruption, intimate partner violence, and placental pathology.
Macrosomia, gestational diabetes, and low parity are not considered risk factors.
Question: 4. A woman in labor is experiencing hypotonic uterine dysfunction. Assessment
reveals no fetopelvic disproportion. Which group of medications would the nurse expect to
administer?
A. sedatives
B. tocolytics
, C. uterine stimulants
D. corticosteroids
Answer:
Answer: C Rationale: For hypotonic labor, a uterine stimulant such as oxytocin may be
prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the
woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics
would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal
lung maturity for women experiencing preterm labor.
Question: 5. A woman gave birth to a newborn via vaginal birth with the use of a vacuum
extractor. The nurse would be alert for which possible effect in the newborn?
A. asphyxia
B. clavicular fracture
C. cephalhematoma
D. central nervous system injury
Answer:
Answer: C Rationale: Use of forceps or a vacuum extractor poses the risk of tissue trauma,
such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and
caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated
with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia.
Central nervous system injury is not associated with the use of a vacuum extractor.
Question: 6. A pregnant client undergoing labor induction is receiving an oxytocin infusion.
Which finding would require immediate intervention?
A. fetal heart rate of 150 beats/minute
B. contractions every 2 minutes, lasting 45 seconds
C. uterine resting tone of 14 mm Hg
D. urine output of 20 mL/hour
Answer:
Answer: D Rationale: Oxytocin can lead to water intoxication. Therefore, a urine output of
20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150
beats/minute is within the accepted range of 120 to 160 beats/minute. Contractions should
occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20
mm Hg would require intervention.
Question: 7. A woman with a history of crack cocaine use disorder is admitted to the labor
and birth area. While caring for the client, the nurse notes a sudden onset of fetal
bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also
reports acute abdominal pain that is continuous. Which condition would the nurse suspect?
A. amniotic fluid embolism
B. shoulder dystocia
C. uterine rupture
D. umbilical cord prolapse
