NUR 1600 Antepartum Exam Review

NUR 1600 Antepartum Exam Review Answer Key Question 1 See full question A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? You Selected: • Latent phase Correct response: • Latent phase Explanation: The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase. Remediation: Question 2 See full question Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? You Selected: • An increase in fetal heart rate variability Correct response: • An increased sense of rectal pressure Explanation: An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur. Remediation: Question 3 See full question A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the health care surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make health care decisions for the fetus, who's responsible for making them? You Selected: • The client's partner Correct response: • The client's partner Explanation: Remediation: Question 4 See full question The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time? You Selected: • lying in the left lateral recumbent position Correct response: • walking around in the hallway Explanation: Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single- room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus. Remediation: Question 5 See full question While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client’s cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? You Selected: • Auscultate the client's blood pressure. Correct response: • Note the color, amount, and odor of the amniotic fluid. Explanation: The nurse’s first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously. After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection. Although auscultating the client’s blood pressure is important, it is not the priority following spontaneous rupture of membranes. Birth is not imminent if the client is 5 cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes. Remediation: Question 6 See full question A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include: You Selected: • perform sterile vaginal examination, increase IV fluids, and apply oxygen. Correct response: • reposition the client, apply oxygen, and increase IV fluids. Explanation: Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth. Remediation: Question 7 See full question A client hospitalized for preterm labor tells the nurse her mother in law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse? You Selected: • “Let’s talk about how preterm labor occurs, so as to help you understand what causes it.” Correct response: • “Let’s talk about how preterm labor occurs, so as to help you understand what causes it.” Explanation: Remediation: Question 8 See full question A couple arrives at the hospital stating that the client’s contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse’s first priority while performing the admission? You Selected: • Review the client’s obstetrical history. Correct response: • Assess the imminence of birth. Explanation: This is the client's fifth baby, and she has been in labor for 3 hours. Given that multipara clients experience the stages of labor at a significantly faster rate than nullipara clients, it is critical that the nurse assess for the imminence of birth. After this has been established, the nurse will know how much time he/she has to review the obstetrical history, assess the client’s coping skills, and ensure the presence of a support person for the labor and birth. Remediation: Question 9 See full question The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month- pregnant woman performs which of the following actions? You Selected: • Cardinal movements Correct response: • Leopold's maneuvers Explanation: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis. The nurse assesses for these through Leopold’s maneuvers, a series of four palpations of the uterus and fetus through the abdominal wall. Cardinal movements are the seven movements that occur as the fetus moves through the birth canal. A digital vaginal exam helps to determine dilation and effacement. The Friedman curve is a graphical representation of cervical dilation and fetal station. Remediation: Question 10 See full question The nurse has just received report on a labor client: a G3, T1, P0, Ab1, L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shift will include address what factors? Select all that apply. You Selected: • Transition will be shorter for this multiparous client. • Pushing the baby out should take 30 minutes or less. • Contractions will remain irregular until transition. Correct response: • This client will give birth before the change of shift in 12 hours. • Pushing the baby out should take 30 minutes or less. • Transition will be shorter for this multiparous client. • This client will withdraw into herself during transition. Explanation: A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from 10-cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a multiparous client than it will for a primiparous client, as the entire labor process takes less time for someone who has had a baby before. This client will withdraw into herself during transition, and this is a common characteristic for those in the transition phase. Answer Key Question 1 See full question A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08- Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for: You Selected: • uterine atony. Correct response: • uterine atony. Explanation: Remediation: Question 2 See full question A client with diabetes mellitus who is in labor tells the nurse she has had trouble controlling her blood glucose level recently. She says she didn't take her insulin when the contractions began because she felt nauseated; about an hour later, when she felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath. What do these findings suggest? You Selected: • Diabetic ketoacidosis Correct response: • Diabetic ketoacidosis Explanation: Remediation: