Maternity Nursing Quiz #4 attached with
solutions 2025/2026 version
what is a prolapsed umbilical cord? - Answer -When the umbilical cord is displaced and comes out of the
vagina before the presenting part
Nursing interventions of a prolapsed umbilical cord - Answer Call for assistance. Do not leave pt. Stay
calm.
Have someone notify PCP
Glove hand and push presenting part up to relieve pressure on cord
Have woman move into knee-chest position (modified Sims position) or extreme Trendelenburg Or place
a rolled towel under the mother's hip
Do not attempt to replace cord into vagina or cervix
If cord is protruding from vagina, loosely wrap it in sterile towel with warm saline
Administer O2 by non-rebreather mask at 8-10 L/min
Start IV or increase existing rate
Monitor FHR
Prepare for delivery
Explain to pt. & partner what is happening
Priority assessments during and after an Amniotomy - Answer Check FHTs
Complications of a massive bleed: s/s disseminated intravascular coagulation - Answer Complication:
Disseminated Intravascular Coagulation (DIC)
•Clotting and anticlotting mechanisms occur at the same time
•Not a primary condition; secondary to pregnancy complications (placental abruption, infection,
preeclampsia/eclampsia, hemorrhage, etc.)
•Manifestations include unusual spontaneous bleeding from gums and nose; oozing , trickling or flow of
blood from incision/laceration; petechiae, hematuria
•Institute emergency measures to control bleeding and impending shock; prepare to transfer to ICU
•Identification of underlying condition and elimination of causative factors are essential
, •Labs: CBC, blood type/cross, clotting factors
•Nursing Care
•Administration of fluid volume replacement (can include blood/blood products)
•Administer pharmacological interventions (antibiotics, vasoactive mediations, uterotonic agents)
•Administer supplemental oxygen
•Protect from injury
Rubin's Taking In Phase - Answer •First 24-36 hours after birth
•Focus on self: rely on others to meet their needs
•Very dependent - may need to be reminded to eat, shower, sleep etc.
•Desire to review birth experience
Rubin's Taking Hold Phase - Answer •Starts 2nd day and lasts approximately 10 days
•Alternates between need for extensive nurturing and a desire to take charge
•Responds enthusiastically to opportunities to learn and practice baby care
•Emotional change - possible experiences with the "blues"
Rubin's Letting-Go Phase - Answer •Focus: forward movement of family as unit with interacting
members
•Reassertion of relationship with partner
•Resolution of individual roles
Nursing Interventions for Perineal Care PP - Answer Pat dry, wipe from front to back, hand hygine before
and after voiding, peribottle with warm water to prevent perineal infections
•Promoting comfort
•Cold and heat applications
•Ice pack (1st 24 hours), peribottle, Sitz bath (after 24 hours)
•Topical preparations
solutions 2025/2026 version
what is a prolapsed umbilical cord? - Answer -When the umbilical cord is displaced and comes out of the
vagina before the presenting part
Nursing interventions of a prolapsed umbilical cord - Answer Call for assistance. Do not leave pt. Stay
calm.
Have someone notify PCP
Glove hand and push presenting part up to relieve pressure on cord
Have woman move into knee-chest position (modified Sims position) or extreme Trendelenburg Or place
a rolled towel under the mother's hip
Do not attempt to replace cord into vagina or cervix
If cord is protruding from vagina, loosely wrap it in sterile towel with warm saline
Administer O2 by non-rebreather mask at 8-10 L/min
Start IV or increase existing rate
Monitor FHR
Prepare for delivery
Explain to pt. & partner what is happening
Priority assessments during and after an Amniotomy - Answer Check FHTs
Complications of a massive bleed: s/s disseminated intravascular coagulation - Answer Complication:
Disseminated Intravascular Coagulation (DIC)
•Clotting and anticlotting mechanisms occur at the same time
•Not a primary condition; secondary to pregnancy complications (placental abruption, infection,
preeclampsia/eclampsia, hemorrhage, etc.)
•Manifestations include unusual spontaneous bleeding from gums and nose; oozing , trickling or flow of
blood from incision/laceration; petechiae, hematuria
•Institute emergency measures to control bleeding and impending shock; prepare to transfer to ICU
•Identification of underlying condition and elimination of causative factors are essential
, •Labs: CBC, blood type/cross, clotting factors
•Nursing Care
•Administration of fluid volume replacement (can include blood/blood products)
•Administer pharmacological interventions (antibiotics, vasoactive mediations, uterotonic agents)
•Administer supplemental oxygen
•Protect from injury
Rubin's Taking In Phase - Answer •First 24-36 hours after birth
•Focus on self: rely on others to meet their needs
•Very dependent - may need to be reminded to eat, shower, sleep etc.
•Desire to review birth experience
Rubin's Taking Hold Phase - Answer •Starts 2nd day and lasts approximately 10 days
•Alternates between need for extensive nurturing and a desire to take charge
•Responds enthusiastically to opportunities to learn and practice baby care
•Emotional change - possible experiences with the "blues"
Rubin's Letting-Go Phase - Answer •Focus: forward movement of family as unit with interacting
members
•Reassertion of relationship with partner
•Resolution of individual roles
Nursing Interventions for Perineal Care PP - Answer Pat dry, wipe from front to back, hand hygine before
and after voiding, peribottle with warm water to prevent perineal infections
•Promoting comfort
•Cold and heat applications
•Ice pack (1st 24 hours), peribottle, Sitz bath (after 24 hours)
•Topical preparations
