Ricci Chapter 14 - Test Bank - 4th Edition || 100% Errorless
Solutions.
1. A woman in labor who received an opioid for pain relief develops respiratory depression. The
nurse would expect which agent to be administered?
A. butorphanol
B. fentanyl
C. naloxone
D. promethazine Correct Answer: C
Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as
respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory
depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the
opioid.
2. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a
contraction. What would the nurse do next?
A. Check the fetal heart rate.
B. Perform a vaginal exam.
C. Notify the primary care provider immediately.
D. Change the linen saver pad. Correct Answer: A
Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to
identify a deceleration, which might indicate cord compression secondary to cord prolapse. A
vaginal exam may be done later to evaluate for continued progression of labor. The primary care
provider should be notified, but this is not a priority at this time. Changing the linen saver pad
would be appropriate once the fetal status is determined and the primary care provider has been
notified.
3. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the
presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding
as:
A. +2 station.
B. 0 station.
C. -2 station.
D. crowning. Correct Answer: C
Rationale: The ischial spines serve as landmarks and are designated as zero status. If the
presenting part is palpated higher than the maternal ischial spines, a negative number is assigned.
Therefore, the nurse would document the finding as -2 station. If the presenting part is below the
ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head
at the vaginal opening.
4. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse
tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:
A. yellow.
B. olive green.
C. pink.
D. blue. Correct Answer: D
, Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain
yellow to olive green suggests that the membranes are most likely intact.
5. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must be
present?
A. intact membranes
B. cervical dilation of 2 cm or more
C. floating presenting fetal part
D. a neonatologist to insert the electrode Correct Answer: B
Rationale: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured
membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow
placement of the electrode, and a skilled practitioner available to insert the electrode.
6. A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement
by the woman would lead the nurse to suspect that the woman needs additional teaching?
A. "The warmth and buoyancy of the water has a nice relaxing effect."
B. "I can stay in the bath for as long as I feel comfortable."
C. "My cervix should be dilated more than 5 cm before I try using this method."
D. "The temperature of the water should be at least 105? (40.5?)." Correct Answer: D
Rationale: Hydrotherapy is an effective pain relief method. The water temperature should not
exceed body temperature. Therefore, a temperature of 105? (40.5?) would be too warm. The
warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as
long as they feel comfortable. The woman should be in active labor with cervical dilation greater
than 5 cm.
7. A woman in labor received an opioid close to the time of birth. The nurse would assess the
newborn for which effect?
A. respiratory depression
B. urinary retention
C. abdominal distention
D. hyperreflexia Correct Answer: A
Rationale: Opioids given close to the time of birth can cause central nervous system depression,
including respiratory depression, in the newborn, necessitating the administration of naloxone.
Urinary retention may occur in the woman who received neuraxial opioids. Abdominal
distention is not associated with opioid administration. Hyporeflexia would be more commonly
associated with central nervous system depression due to opioids.
8. When applying the ultrasound transducer for continuous external electronic fetal monitoring,
the nurse would place the transducer at which location on the client's body to record the FHR?
A. over the uterine fundus where contractions are most intense
B. above the umbilicus toward the right side of the diaphragm
C. between the umbilicus and the symphysis pubis
D. between the xiphoid process and umbilicus Correct Answer: C
Rationale: The ultrasound transducer is positioned on the maternal abdomen in the midline
between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine
Solutions.
1. A woman in labor who received an opioid for pain relief develops respiratory depression. The
nurse would expect which agent to be administered?
A. butorphanol
B. fentanyl
C. naloxone
D. promethazine Correct Answer: C
Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as
respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory
depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the
opioid.
2. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a
contraction. What would the nurse do next?
A. Check the fetal heart rate.
B. Perform a vaginal exam.
C. Notify the primary care provider immediately.
D. Change the linen saver pad. Correct Answer: A
Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to
identify a deceleration, which might indicate cord compression secondary to cord prolapse. A
vaginal exam may be done later to evaluate for continued progression of labor. The primary care
provider should be notified, but this is not a priority at this time. Changing the linen saver pad
would be appropriate once the fetal status is determined and the primary care provider has been
notified.
3. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the
presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding
as:
A. +2 station.
B. 0 station.
C. -2 station.
D. crowning. Correct Answer: C
Rationale: The ischial spines serve as landmarks and are designated as zero status. If the
presenting part is palpated higher than the maternal ischial spines, a negative number is assigned.
Therefore, the nurse would document the finding as -2 station. If the presenting part is below the
ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head
at the vaginal opening.
4. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse
tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:
A. yellow.
B. olive green.
C. pink.
D. blue. Correct Answer: D
, Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain
yellow to olive green suggests that the membranes are most likely intact.
5. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must be
present?
A. intact membranes
B. cervical dilation of 2 cm or more
C. floating presenting fetal part
D. a neonatologist to insert the electrode Correct Answer: B
Rationale: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured
membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow
placement of the electrode, and a skilled practitioner available to insert the electrode.
6. A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement
by the woman would lead the nurse to suspect that the woman needs additional teaching?
A. "The warmth and buoyancy of the water has a nice relaxing effect."
B. "I can stay in the bath for as long as I feel comfortable."
C. "My cervix should be dilated more than 5 cm before I try using this method."
D. "The temperature of the water should be at least 105? (40.5?)." Correct Answer: D
Rationale: Hydrotherapy is an effective pain relief method. The water temperature should not
exceed body temperature. Therefore, a temperature of 105? (40.5?) would be too warm. The
warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as
long as they feel comfortable. The woman should be in active labor with cervical dilation greater
than 5 cm.
7. A woman in labor received an opioid close to the time of birth. The nurse would assess the
newborn for which effect?
A. respiratory depression
B. urinary retention
C. abdominal distention
D. hyperreflexia Correct Answer: A
Rationale: Opioids given close to the time of birth can cause central nervous system depression,
including respiratory depression, in the newborn, necessitating the administration of naloxone.
Urinary retention may occur in the woman who received neuraxial opioids. Abdominal
distention is not associated with opioid administration. Hyporeflexia would be more commonly
associated with central nervous system depression due to opioids.
8. When applying the ultrasound transducer for continuous external electronic fetal monitoring,
the nurse would place the transducer at which location on the client's body to record the FHR?
A. over the uterine fundus where contractions are most intense
B. above the umbilicus toward the right side of the diaphragm
C. between the umbilicus and the symphysis pubis
D. between the xiphoid process and umbilicus Correct Answer: C
Rationale: The ultrasound transducer is positioned on the maternal abdomen in the midline
between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine
