NURSING MISC Focus on Maternity Health(Questions and Answers) 100% Correct, Fall 2019

A nurse assists the health care provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy? Assign the number 1 to the first action and the number 5 to the last action.
Correct A. Determining the fetal heart rate B. Noting the quantity, color, and odor of the amniotic fluid C. Taking the client’s temperature, pulse, and blood pressure D. Replacing soiled underpads from beneath the client’s buttocks E. Planning evaluation of the client for signs and symptoms of infection
Rationale: After amniotomy, the fetal heart rate is assessed for at least 1 full minute for changes associated with prolapse or compression of the umbilical cord and the characteristics of the fluid are noted as an indicator of fetal risk. After the fluid has been assessed, the next concern is evaluation of the maternal vital signs. The client’s comfort (i.e., the soiled underpads) is considered next. With the ruptured membranes comes an increased risk for maternal infection. For this reason, the client is frequently assessed for signs and symptoms of infection throughout the course of labor.
Test-Taking Strategy: Use principles of prioritizing and your knowledge of the ABCs (airway, breathing, and circulation) to answer this question. Fetal heart rate is associated with fetal breathing and circulation. Once the fetal condition has been assessed, the focus is turned to the mother’s condition. The amniotic fluid is checked next because this action will take little time, followed by vital signs. Finally client comfort is provided, followed by the planning of further care. If you had difficulty with this question, review the priority nursing actions after amniotomy.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Care Coordination, Reproduction
HESI Concepts: Collaboration/Managing Care – Care Coordination, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 412-414). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
22.ID: 4
A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the health care provider? A. Maternal fatigue B. Clear amniotic fluid C. Strong-smelling amniotic fluid Correct D. A fetal heart rate of 140 beats/min
Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38° C or 100.4° F), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor.
Test-Taking Strategy: Focus on the subject of the question, a sign of intrauterine infection. Eliminate the options that are comparable or alike in that they are normal expectations during labor. Review the signs of intrauterine infection if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Intrapartum
Giddens Concepts: Clinical Judgment, Infection
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 643-644). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
23.ID: 1
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client? A. Providing pain relief Correct B. Preparing the client for amniotomy C. Monitoring the oxytocin (Pitocin) infusion closely D. Encouraging the client to ambulate every 30 minutes E.
Rationale: Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes.
Test-Taking Strategy: Use the process of elimination, focusing on the strategic words “hypertonic” and “priority.” This, plus knowledge of the management of this condition, should direct you to the correct option. Also eliminate the options that are therapeutic measures for hypotonic uterine dysfunction and would stimulate labor (i.e., oxytocin augmentation and amniotomy). If you had difficulty with this question, review the management of hypertonic uterine dysfunction.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 636-637). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
24.ID: 2
A nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority? A. Monitoring fetal status Correct B. Providing comfort measures C. Changing the client’s position D. Informing the client’s partner of the progress of the labor E.
Rationale: The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client’s partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority.
Test-Taking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory and your knowledge of the ABCs (airway, breathing, and circulation) to answer the question. Remember that physiological needs are the priority. Review priority nursing interventions for the client with dystocia if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Care Coordination, Reproduction
HESI Concepts: Collaboration/Managing Care – Care Coordination, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 609, 636). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
25.ID: 3
A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: A. At any time B. In 2 to 4 weeks Correct C. After the 6-week health care provider checkup D. When her normal menstrual period has resumed
Rationale: Usually a woman may engage safely in sexual intercourse during the second to fourth week after childbirth as long as she experiences no discomfort during intercourse. The other options are incorrect. Engaging in intercourse too early in the postpartum course could result in further injury to perineal tissues damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth.
Test-Taking Strategy: Knowledge of the instructions given to a new mother regarding sexual activity after delivery is required to answer this question. Recalling that it takes about 3 weeks for an episiotomy to heal will direct you to the correct option. Review postpartum instructions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Postpartum
Giddens Concepts: Sexuality, Safety
HESI Concepts: Sexuality/Reproduction, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 449). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
26.ID: 1
A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: A. The infant must be isolated from the mother after birth Incorrect B. Maternal medication will not be started until the baby is born C. The infant will require medication therapy immediately after birth D. The mother may need to take isoniazid, pyrazinamide, and rifampin (Rifadin) for a total of 9 months Correct
Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital.
Test-Taking Strategy: Knowledge regarding the therapeutic management of the mother with tuberculosis and that of the infant is required to answer this question. Eliminate the options containing the closed-ended words “must,” “not,” and “immediately.” If you had difficulty with this question, review treatment measures for the mother with tuberculosis.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Client Education, Infection
HESI Concepts: Infection, Teaching and Learning/Patient Education
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 631). St. Louis: Elsevier.
Awarded 0.0 points out of 1.0 possible points.
27.ID: 8
A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is:
A. At +1 station B. At –1 station C. At zero station Correct D. Stationed at the bottom of the coccyx E.
Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line.
Test-Taking Strategy: Knowing that station is measured in centimeters, with the ischial spines as a reference point, will assist you in answering this question. Focus on the figure and note that the fetal head is at zero station. Review station if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 330-331). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
28.ID: 7
A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: A. Supine, on the left side B. Supine, on the right side C. Lying down with the arm in a horizontal position at heart level D. In a sitting position with the arm in a horizontal position at heart level E. Correct
Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client sitting position and the arm supported in a horizontal position at heart level. Supine on the right or left side and lying down with the arm in a horizontal position at heart level are both incorrect and could cause physiological stress that would affect the blood pressure.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve indicate positioning the client lying down or supine. If you are unfamiliar with the procedure of taking a pregnant client’s blood pressure, review this procedure.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Assessment, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 248). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
29.ID: 8
A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? A. 20 cm Correct B. 28 cm C. 32 cm D. 40 cm
Rationale: During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman’s bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present.
Test-Taking Strategy: Knowledge regarding the expected findings in fundal height during the second or third trimester is required to answer this question. Remember that the height of the fundus in centimeters during the second and third trimesters is approximately the same as the number of weeks of gestation. If you are unfamiliar with the interpretation of fundal height, review this content.
Level of Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 250-251, 434). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.