Chapter 11 Shock, Sepsis, and Multiple Organ Dysfunction
Syndrome
1.A woman in labor who received an opioid for pain relief develops respiratory depression. The
nurse would expect which agent to be administered?
A) Butorphanol
B) Fentanyl
C) Naloxone
D) Promethazine
Ans: C
Feedback:
Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory
depression. Butorphanol and fentanyl are opioids and would cause further respiratory
depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of
the opioid.
2.A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a
contraction. Which of the following would the nurse do next?
A) Check the fetal heart rate. B) Perform a vaginal exam.
C) Notify the physician immediately. D) Change the linen saver pad.
Ans: A
Feedback:
When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a
deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal
exam may be done later to evaluate for continued progression of
, labor. The physician should be notified, but this is not a priority at this time. Changing the
linen saver pad would be appropriate once the fetal status is determined and the physician
has been notified.
3.A woman has just entered the second stage of labor. The nurse would focus care on which of
the following?
A) Encouraging the woman to push when she has a strong desire to do so
B) Alleviating perineal discomfort with the application of ice packs
C) Palpating the woman's fundus for position and firmness
D) Completing the identification process of the newborn with the mother
Ans: A
Feedback:
During the second stage of labor, nursing interventions focus on motivating the woman,
encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice
packs and palpating the woman's fundus would be appropriate during the fourth stage of
labor. Completing the newborn identification process would be appropriate during the third
stage of labor.
4.The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the
following would the nurse do next?
A) Continue to monitor the FHR because this pattern is benign.
B) Perform a vaginal exam to assess cervical dilation and effacement. C)
Stay with the client while reporting the finding to the physician.
D) Administer oxygen after turning the client on her left side. Ans: A
Feedback:
, Early decelerations are not indicative of fetal distress and do not require intervention.
Therefore, the nurse would continue to monitor the fetal heart rate pattern. They are most
often seen during the active stage of any normal labor, during pushing, crowning, or vacuum
extraction. They are thought to be a result of fetal head compression that results in a reflex
vagal response with a resultant slowing of the FHR during uterine
contractions. There is no need to perform a vaginal exam, report the finding to the physician,
or administer oxygen.
5.A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the
presenting part is approximately 2 cm above the ischial spines. The nurse documents this
finding as:
A) +2 station B) 0 station C) –2 station D) Crowning Ans:
C
Feedback:
The ischial spines serve as landmarks and are designated as zero status. If the presenting part
is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore,
the nurse would document the finding as –2 station. If the presenting part is below the ischial
spines, then the station would be +2. Crowning refers to the appearance of the fetal head at
the vaginal opening.
6.The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and
lie. Which action would the nurse do first?
A) Feel for the fetal buttocks or head while palpating the abdomen.
B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C)
Palpate for the presenting part in the area just above the symphysis pubis.
Syndrome
1.A woman in labor who received an opioid for pain relief develops respiratory depression. The
nurse would expect which agent to be administered?
A) Butorphanol
B) Fentanyl
C) Naloxone
D) Promethazine
Ans: C
Feedback:
Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory
depression. Butorphanol and fentanyl are opioids and would cause further respiratory
depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of
the opioid.
2.A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a
contraction. Which of the following would the nurse do next?
A) Check the fetal heart rate. B) Perform a vaginal exam.
C) Notify the physician immediately. D) Change the linen saver pad.
Ans: A
Feedback:
When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a
deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal
exam may be done later to evaluate for continued progression of
, labor. The physician should be notified, but this is not a priority at this time. Changing the
linen saver pad would be appropriate once the fetal status is determined and the physician
has been notified.
3.A woman has just entered the second stage of labor. The nurse would focus care on which of
the following?
A) Encouraging the woman to push when she has a strong desire to do so
B) Alleviating perineal discomfort with the application of ice packs
C) Palpating the woman's fundus for position and firmness
D) Completing the identification process of the newborn with the mother
Ans: A
Feedback:
During the second stage of labor, nursing interventions focus on motivating the woman,
encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice
packs and palpating the woman's fundus would be appropriate during the fourth stage of
labor. Completing the newborn identification process would be appropriate during the third
stage of labor.
4.The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the
following would the nurse do next?
A) Continue to monitor the FHR because this pattern is benign.
B) Perform a vaginal exam to assess cervical dilation and effacement. C)
Stay with the client while reporting the finding to the physician.
D) Administer oxygen after turning the client on her left side. Ans: A
Feedback:
, Early decelerations are not indicative of fetal distress and do not require intervention.
Therefore, the nurse would continue to monitor the fetal heart rate pattern. They are most
often seen during the active stage of any normal labor, during pushing, crowning, or vacuum
extraction. They are thought to be a result of fetal head compression that results in a reflex
vagal response with a resultant slowing of the FHR during uterine
contractions. There is no need to perform a vaginal exam, report the finding to the physician,
or administer oxygen.
5.A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the
presenting part is approximately 2 cm above the ischial spines. The nurse documents this
finding as:
A) +2 station B) 0 station C) –2 station D) Crowning Ans:
C
Feedback:
The ischial spines serve as landmarks and are designated as zero status. If the presenting part
is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore,
the nurse would document the finding as –2 station. If the presenting part is below the ischial
spines, then the station would be +2. Crowning refers to the appearance of the fetal head at
the vaginal opening.
6.The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and
lie. Which action would the nurse do first?
A) Feel for the fetal buttocks or head while palpating the abdomen.
B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C)
Palpate for the presenting part in the area just above the symphysis pubis.
