NRSG 3302 WOMEN AND FAMILIES EXAM 2
A patient has been laboring for over 18 hours when the provider ruptures her
membranes. The fetus experiences a prolonged deceleration immediately following the
procedure. Which is the priority nursing action for this patient?
1.
Notify the provider.
2.
Administer an IV fluid bolus.
3.
Change the maternal position.
4.
Perform a vaginal exam. - Answer -3.
Change the maternal position.
The nurse notifies the provider that the patient has a Category III tracing and
discontinued the oxytocin. The provider orders the nurse to restart the oxytocin infusion.
Which is the most appropriate action by the nurse to minimize risks to the patient?
1.
Refuse to restart the oxytocin.
2.
Communicate concerns to the provider about restarting oxytocin and use the chain of
command if necessary.
3.
Restart the oxytocin as ordered.
4.
Document the communication and concerns that were discussed, then restart the
oxytocin as ordered. - Answer -2.
Communicate concerns to the provider about restarting oxytocin and use the chain of
command if necessary.
The nurse evaluates the tracing on a patient and notices 6 contractions in 10 minutes.
Which assessment regarding the contraction pattern is priority?
1.
What is the intensity?
2.
What is the duration?
3.
What is the resting tone?
4.
What are possible causes? - Answer -4.
What are possible causes?
,A nurse is monitoring a patient who is 26 weeks gestation and in preterm labor. Which
assessment data does the nurse document as a normal finding?
1.
Minimal variability
2.
FHR 168
3.
Late decelerations
4.
Contractions every 3 to 4 minutes - Answer -1.
Minimal variability
Which plan would be most appropriate for monitoring a patient who presents to the
labor and delivery unit in the active phase of labor with ruptured membranes?
1.
At least hourly by auscultation
2.
Every 30 minutes by electronic fetal heart monitoring
3.
Every 15-30 minutes by auscultation
4.
Every 15 minutes by electronic fetal heart monitoring - Answer -4.
Every 15 minutes by electronic fetal heart monitoring
During a childbirth education class, the nurse educator describes signs of impending
labor. Which statement made by a class participant requires further teaching?
1.
"I may experience a sudden surge of energy, or a 'nesting' instinct, as labor
approaches"
2.
"It may be more difficult to breathe as the baby gets larger toward my due date."
3.
"It's normal to experience warm-up contractions that aren't painful before the real thing."
4.
"I could feel some increasing lower back and hip discomfort" - Answer -2.
"It may be more difficult to breathe as the baby gets larger toward my due date."
Which patient with a fetus displaying minimal variability would the nurse assess first?
1.
A patient who received nalbuphine 10 mg slow IV push 10 minutes ago
2.
A patient who is 25 weeks gestation with intermittent contractions
3.
A patient who is 39 weeks gestation with 8 contractions in 10 minutes
4.
,A patient who is 37 weeks gestation contracting every 6 to 7 minutes with no
accelerations - Answer -3.
A patient who is 39 weeks gestation with 8 contractions in 10 minutes
The nurse is caring for a patient who is a G4P3 at 38 weeks gestation, contracting every
3 minutes. Which assessment finding by the nurse requires immediate action?
1.
FHR of 105 per minute for the last 15 minutes
2.
Variable decelerations with 2 contractions
3.
Minimal variability
4.
Contraction duration of 60-70 seconds - Answer -3.
Minimal variability
To improve fetal oxygenation and decrease maternal exhaustion during second stage
labor, what would the nurse instruct the client to do?
1.
Take deep breaths from the nitrous oxide mask before pushing.
2.
Perform pant-blow breathing during the peak of a contraction.
3.
Use the Valsalva maneuver as the nurse directs pushing.
4.
Wait until there is a strong urge to push to begin bearing down efforts. - Answer -4.
Wait until there is a strong urge to push to begin bearing down efforts.
The nurse is caring for a client in the first stage labor. To assist the progression of labor,
the nurse recommends:
1.
Changing positions and sitting upright
2.
Maintaining a side-lying position only
3.
Receiving an epidural as early as possible so she can relax and rest
4.
Limiting visitors at the beside to promote rest - Answer -1.
Changing positions and sitting upright
Following the delivery of a term newborn, the mother experiences a moderate urge to
push and a gush of blood emerges from the vagina. The nurse recognizes this as:
1.
Indicating the placenta is about to deliver
2.
The formation of a vaginal hematoma
, 3.
Perform a cervical exam
4.
Signs of a postpartum hemorrhage - Answer -1.
Indicating the placenta is about to deliver
Immediately following the delivery of the placenta, the nurse prepares to administer IV
oxytocin. The client states, "What is this medication for?" which is the nurse's best
response?
1.
"To augment labor contractions"
2.
"To improve the let-down reflex for your breastmilk."
3.
"To prevent hemorrhage after delivery."
4.
"To prevent uterine cramping and pain following delivery." - Answer -3.
"To prevent hemorrhage after delivery."
The nurse is caring for a client being augmented with oxytocin. What potential
complications should the nurse observe the client for? Select all that apply.
1.
Tachysystole
2.
Late decelerations on the fetal monitor
3.
Episodic accelerations
4.
Uterine rupture
5.
Maternal edema - Answer -1.
Tachysystole
2.
Late decelerations on the fetal monitor
4.
Uterine rupture
5.
Maternal edema
The nurse initiates a fluid bolus prior to epidural administration. which is the purpose of
this action?
1.
To stabilize post-epidural blood pressure
2.
To prevent hypovolemia following blood loss after delivery
3.
A patient has been laboring for over 18 hours when the provider ruptures her
membranes. The fetus experiences a prolonged deceleration immediately following the
procedure. Which is the priority nursing action for this patient?
1.
Notify the provider.
2.
Administer an IV fluid bolus.
3.
Change the maternal position.
4.
Perform a vaginal exam. - Answer -3.
Change the maternal position.
The nurse notifies the provider that the patient has a Category III tracing and
discontinued the oxytocin. The provider orders the nurse to restart the oxytocin infusion.
Which is the most appropriate action by the nurse to minimize risks to the patient?
1.
Refuse to restart the oxytocin.
2.
Communicate concerns to the provider about restarting oxytocin and use the chain of
command if necessary.
3.
Restart the oxytocin as ordered.
4.
Document the communication and concerns that were discussed, then restart the
oxytocin as ordered. - Answer -2.
Communicate concerns to the provider about restarting oxytocin and use the chain of
command if necessary.
The nurse evaluates the tracing on a patient and notices 6 contractions in 10 minutes.
Which assessment regarding the contraction pattern is priority?
1.
What is the intensity?
2.
What is the duration?
3.
What is the resting tone?
4.
What are possible causes? - Answer -4.
What are possible causes?
,A nurse is monitoring a patient who is 26 weeks gestation and in preterm labor. Which
assessment data does the nurse document as a normal finding?
1.
Minimal variability
2.
FHR 168
3.
Late decelerations
4.
Contractions every 3 to 4 minutes - Answer -1.
Minimal variability
Which plan would be most appropriate for monitoring a patient who presents to the
labor and delivery unit in the active phase of labor with ruptured membranes?
1.
At least hourly by auscultation
2.
Every 30 minutes by electronic fetal heart monitoring
3.
Every 15-30 minutes by auscultation
4.
Every 15 minutes by electronic fetal heart monitoring - Answer -4.
Every 15 minutes by electronic fetal heart monitoring
During a childbirth education class, the nurse educator describes signs of impending
labor. Which statement made by a class participant requires further teaching?
1.
"I may experience a sudden surge of energy, or a 'nesting' instinct, as labor
approaches"
2.
"It may be more difficult to breathe as the baby gets larger toward my due date."
3.
"It's normal to experience warm-up contractions that aren't painful before the real thing."
4.
"I could feel some increasing lower back and hip discomfort" - Answer -2.
"It may be more difficult to breathe as the baby gets larger toward my due date."
Which patient with a fetus displaying minimal variability would the nurse assess first?
1.
A patient who received nalbuphine 10 mg slow IV push 10 minutes ago
2.
A patient who is 25 weeks gestation with intermittent contractions
3.
A patient who is 39 weeks gestation with 8 contractions in 10 minutes
4.
,A patient who is 37 weeks gestation contracting every 6 to 7 minutes with no
accelerations - Answer -3.
A patient who is 39 weeks gestation with 8 contractions in 10 minutes
The nurse is caring for a patient who is a G4P3 at 38 weeks gestation, contracting every
3 minutes. Which assessment finding by the nurse requires immediate action?
1.
FHR of 105 per minute for the last 15 minutes
2.
Variable decelerations with 2 contractions
3.
Minimal variability
4.
Contraction duration of 60-70 seconds - Answer -3.
Minimal variability
To improve fetal oxygenation and decrease maternal exhaustion during second stage
labor, what would the nurse instruct the client to do?
1.
Take deep breaths from the nitrous oxide mask before pushing.
2.
Perform pant-blow breathing during the peak of a contraction.
3.
Use the Valsalva maneuver as the nurse directs pushing.
4.
Wait until there is a strong urge to push to begin bearing down efforts. - Answer -4.
Wait until there is a strong urge to push to begin bearing down efforts.
The nurse is caring for a client in the first stage labor. To assist the progression of labor,
the nurse recommends:
1.
Changing positions and sitting upright
2.
Maintaining a side-lying position only
3.
Receiving an epidural as early as possible so she can relax and rest
4.
Limiting visitors at the beside to promote rest - Answer -1.
Changing positions and sitting upright
Following the delivery of a term newborn, the mother experiences a moderate urge to
push and a gush of blood emerges from the vagina. The nurse recognizes this as:
1.
Indicating the placenta is about to deliver
2.
The formation of a vaginal hematoma
, 3.
Perform a cervical exam
4.
Signs of a postpartum hemorrhage - Answer -1.
Indicating the placenta is about to deliver
Immediately following the delivery of the placenta, the nurse prepares to administer IV
oxytocin. The client states, "What is this medication for?" which is the nurse's best
response?
1.
"To augment labor contractions"
2.
"To improve the let-down reflex for your breastmilk."
3.
"To prevent hemorrhage after delivery."
4.
"To prevent uterine cramping and pain following delivery." - Answer -3.
"To prevent hemorrhage after delivery."
The nurse is caring for a client being augmented with oxytocin. What potential
complications should the nurse observe the client for? Select all that apply.
1.
Tachysystole
2.
Late decelerations on the fetal monitor
3.
Episodic accelerations
4.
Uterine rupture
5.
Maternal edema - Answer -1.
Tachysystole
2.
Late decelerations on the fetal monitor
4.
Uterine rupture
5.
Maternal edema
The nurse initiates a fluid bolus prior to epidural administration. which is the purpose of
this action?
1.
To stabilize post-epidural blood pressure
2.
To prevent hypovolemia following blood loss after delivery
3.
