Hsa Nr222

1. Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid ANS: B The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the patient is in active labor ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care Environment 3. A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2C (99F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates ANS: C NURSINGTB.COM Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank NU RS IN GT B.CO M Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C (100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Physiologic Integrity 4. A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position. ANS: B A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity