EXAM 2 TEST BANK SOLVED QUESTIONS 100 PERCENT CORRECT ANSWERS
Question:
What are changes that prepare the fetus for respirations immediately before birth?
Answer:
-fluid is cleared from the fetal lungs fetal oxygen concentration is decreased Arterial CO2 increases
Bicarbonate level decreases Fetal resp movements decrease during labor
Question:
Mixed opioids that provide analgesia without causing respiratory depression?
Answer:
Butorphanol, nalbuphine
Question:
What are nursing considerations when administering an epidural?
Answer:
•Have patient void before procedure, place in- dwelling catheter per protocol after procedure -
causes bladder distension; and monitor V/S cont. and EFM S/E: maternal hypotension, increased
temp., bladder distension, prolonged 1st and 2nd stage of labor; increased incidence of c- section
Question:
Nonpharmacologic pain management
Answer:
§Counterpressure § Effleurage (light massage) §Therapeutic touch and massage §Walking
§Rocking §Changing positions §Application of heat or cold §Transcutaneous electrical nerve
stimulation (TENS) §Acupressure §Water therapy (showers, baths, whirlpool baths) §Intradermal
,water block
Question:
What are contraindication of iron sulfate?
Answer:
Hemolytic anemia, peptic ulcer, UC take on an empty stomach at bedtime
Question:
In what situations do we see fetal tachycardia? Fetal bradycardia?
Answer:
Maternal fever, infection, fetal anemia, medications (atropine, hydroxyzine, terbutaline, cocaine,
meth) Viral infections, maternal hypoglycemia, maternal hypothermia, fetal cardiac problem,
maternal mag infusion
Question:
What causes sinusoidal patterns?
Answer:
severe fetal anemia such as with Rh incompatibility and sensitization
Question:
What does absent or minimal variability indicate?
Answer:
Fetal hypoxemia or metabolic acidemia
Question:
What are some causes of late decels? What are the nursing interventions to be used here?
Answer:
,Low maternal blood volume/pressure, supine hypotension, preeclampsia, use of epidural, uterine
tachysystole POISON: reposition to left side, give O2 (10 l -Non rebreather mask), IV fluid bolus,
sterile vag exam, stop oxytocin, notify MD
Question:
What is the main intervention for variable decels?
Answer:
Reposition mom - if ineffective, may require an amnioinfusion to relieve pressure/compression
placed on umbilical cord - also indicated for oligohydramnios Assist with vaginal or speculum
examination to assess for cord prolapse may also indicate a nuchal cord, knots, or just be uterine
contractions
Question:
prolonged deceleration
Answer:
visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 beats/min below
the baseline and lasting more than 2 minutes but less than 10 minutes >10 min= baseline change
Question:
What are nursing considerations with an amnioinfusion?
Answer:
Uterine tone must be monitored as overdistention of the uterus may occur. Resting tone will be
higher during amnioinfusion but should not exceed 40mmHg throughout the procedure. Fluid in and
fluid out should also be monitored.
Question:
How long does a fetal sleep cycle last normally? When do we begin vibroacoustic stimulation
Answer:
20 min; 40 min - VS
, Question:
What are nursing interventions for each stage of labor?
Answer:
1: Encourage voiding q2 hr; change position q30-60 min
Question:
What is the frequency and duration of contractions in the second stage of labor?
Answer:
Freq: 2-3 min, then 1-2 Duration: 90 min
Question:
What are appropriate nursing interventions for the second stage of labor?
Answer:
Immediate skin to skin contact (if stable) Delayed cord clamping Apgar scores
Question:
What are appropriate nursing interventions for the third stage of labor?
Answer:
Fundal massage
Question:
How often do you take V/S in the the fourth stage of labor?
Answer:
B/P and pulse: q15min for first 2 hours Temp: initially then q4 hrs for 1st 8 hrs then q8hrs
Question:
What are changes that prepare the fetus for respirations immediately before birth?
Answer:
-fluid is cleared from the fetal lungs fetal oxygen concentration is decreased Arterial CO2 increases
Bicarbonate level decreases Fetal resp movements decrease during labor
Question:
Mixed opioids that provide analgesia without causing respiratory depression?
Answer:
Butorphanol, nalbuphine
Question:
What are nursing considerations when administering an epidural?
Answer:
•Have patient void before procedure, place in- dwelling catheter per protocol after procedure -
causes bladder distension; and monitor V/S cont. and EFM S/E: maternal hypotension, increased
temp., bladder distension, prolonged 1st and 2nd stage of labor; increased incidence of c- section
Question:
Nonpharmacologic pain management
Answer:
§Counterpressure § Effleurage (light massage) §Therapeutic touch and massage §Walking
§Rocking §Changing positions §Application of heat or cold §Transcutaneous electrical nerve
stimulation (TENS) §Acupressure §Water therapy (showers, baths, whirlpool baths) §Intradermal
,water block
Question:
What are contraindication of iron sulfate?
Answer:
Hemolytic anemia, peptic ulcer, UC take on an empty stomach at bedtime
Question:
In what situations do we see fetal tachycardia? Fetal bradycardia?
Answer:
Maternal fever, infection, fetal anemia, medications (atropine, hydroxyzine, terbutaline, cocaine,
meth) Viral infections, maternal hypoglycemia, maternal hypothermia, fetal cardiac problem,
maternal mag infusion
Question:
What causes sinusoidal patterns?
Answer:
severe fetal anemia such as with Rh incompatibility and sensitization
Question:
What does absent or minimal variability indicate?
Answer:
Fetal hypoxemia or metabolic acidemia
Question:
What are some causes of late decels? What are the nursing interventions to be used here?
Answer:
,Low maternal blood volume/pressure, supine hypotension, preeclampsia, use of epidural, uterine
tachysystole POISON: reposition to left side, give O2 (10 l -Non rebreather mask), IV fluid bolus,
sterile vag exam, stop oxytocin, notify MD
Question:
What is the main intervention for variable decels?
Answer:
Reposition mom - if ineffective, may require an amnioinfusion to relieve pressure/compression
placed on umbilical cord - also indicated for oligohydramnios Assist with vaginal or speculum
examination to assess for cord prolapse may also indicate a nuchal cord, knots, or just be uterine
contractions
Question:
prolonged deceleration
Answer:
visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 beats/min below
the baseline and lasting more than 2 minutes but less than 10 minutes >10 min= baseline change
Question:
What are nursing considerations with an amnioinfusion?
Answer:
Uterine tone must be monitored as overdistention of the uterus may occur. Resting tone will be
higher during amnioinfusion but should not exceed 40mmHg throughout the procedure. Fluid in and
fluid out should also be monitored.
Question:
How long does a fetal sleep cycle last normally? When do we begin vibroacoustic stimulation
Answer:
20 min; 40 min - VS
, Question:
What are nursing interventions for each stage of labor?
Answer:
1: Encourage voiding q2 hr; change position q30-60 min
Question:
What is the frequency and duration of contractions in the second stage of labor?
Answer:
Freq: 2-3 min, then 1-2 Duration: 90 min
Question:
What are appropriate nursing interventions for the second stage of labor?
Answer:
Immediate skin to skin contact (if stable) Delayed cord clamping Apgar scores
Question:
What are appropriate nursing interventions for the third stage of labor?
Answer:
Fundal massage
Question:
How often do you take V/S in the the fourth stage of labor?
Answer:
B/P and pulse: q15min for first 2 hours Temp: initially then q4 hrs for 1st 8 hrs then q8hrs
