ADN 240 exam 1 with 100% correct answers 2024

EDC/EDD - answer-estimated date of confinement/ estimated date of delivery GPTAL - answer-gravidity, preterm, term, abortions, living children -gravida - answer-number of pregnancies Para - answer-Number of pregnancies delivered after age of viability. Term (37 weeks). Preterm (20-37 weeks). Abortions - answer-Number of terminated pregnancies, spontaneous or induced Living children - answer-number of living children they've birthed. Multiples are counted as one in GPTAL presumptive changes (subjective) - answer-Amenorrhea, nausea, vomiting, fatigue, urinary frequency, changes in breast, quickening (first movement of fetus Probable changes (objective) - answer-Changes in pelvic organs, enlargement of abdomen, Braxton hicks, changes in skin pigmentation, at home pregnancy tests Diagnostic (by the provider) - answer-Fetal heart beat, feta movement, visualization of the fetus Diagnostic tests that occur during pregnancy - answer-Pregnancy test, PAP smear, complete blood count, hemoglobin, rubella tiger- 1:10 immune, ABO/RH typing, Hep B screen, STI testing, quadrupole screen- genetic testing, Amniocentisis, glucose screen, no stress test, ultrasound Anemia primary type - answer-Hub normal is 14-16, anything below that Hypertensive disorders - answer-Transient=pregnancy induced hypertension, can lead to preeclampsia/eclampsia or HELLP count syndrom ABO and Rh Incompatibility - answer-issues when the mother's blood type is negative and the infant's blood type is positive. Direct Coombs: baby. Indirect Coombs: mother Pharm during pregnancy - answer-Prenatal vitamin and folic acid for over the counter Tocolytic is given for - answer-Mag sulfate-preterm labor suppression and seizure preventative Cortocosteroids are given for - answer-Bentamethasone- prior to 34 weeks for lung maturity. This comes in 2 doses 24 hours apart Hydralazine is given for - answer-Antihypertensive given IVP` Passage - answer-The pelvis, gynecology pelvis is adequate for childbirth, determines ability to deliver, dilation, effacement, station, position, also able to asses presenting part, membrane status, cervical change, and perineal stretching Passenger - answer-The baby, need to know how many, position,, attitude (chin tucked-flextion) (chin extended-extension) Vertex - answer-Head down Frank breech - answer-Leg extended to head Full breach - answer-Knees tucked Footling breach - answer-Foot extended Station - answer-Relationship of presenting part to the ischial spine -1 to -5 is unengaged above ischial spines 0 at ischial spines +1 to +5 is below ischial spines +5 is crowning Power - answer-uterine force- contractions, nutrition/fluids, rest/fatigue to efface and dilate. Forces to expel the fetus (pushing) Maternal position - answer-How the mother is situated (change positions frequently to help with pain Psych - answer-Plays a huge role in birth, provide education, reduce fear, provide pt confidence, provide support Position fetal - answer-relationship of a reference point on the fetal presenting part to the four quadrants of the maternal pelvis Most common and easiest position to deliver - answer-Occipital anterior Presentation of the fetus - answer-the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor Malpresentation - answer-Breech/shoulder, the labor will not proceed Lie - answer-relationship between spine of baby and spine of mom parallel = vertical lie = good Horizontal = transverse lie = bad Signs of impending labor - answer-Lightening, engagement of head, weight loss false labor - answer-Irregular contractions, walking helps, not intense pain True labor - answer-regular contractions, produce dilation and effacement of cervix, start in the back and radiate around to the abdomen, not relieved by walking External fetal monitoring allows for? - answer-Able to see oxygenation, uterine contractions, External fetal monitoring is - answer-Bulky and uncomfortable to wear, it is also cheaper Decelerations - answer-Early: head compression, no intervention Late: insufficient oxygen transfer, could be due to decreased maternal BP Variable: cord compression, assess and reposition the patient Accelerations - answer-Fetus moves in response to contractions Internal monitoring - answer-Invasive, expensive, more difficult to move around Doppler/fetoscope - answer-Can obtain same as external fetal monitoring Frequency - answer-Time between beginning of one contraction and beginning of next Duration - answer-Beginning of contraction to the end of the same contraction Intensity - answer-the strength of the contraction during the highest point How to tell intensity - answer-If it feels like your nose it is mild If it feels like your chin it is moderate If it feels like your forehead it is strong First stage of labor - answer-Effacement and dilation is occurring. This phase is broken up into latent, active, and transition phases Latent labor - answer-Onset of regular contractions. 0-4 cm. Able to cope with pain, contractions 5-10 min apart, 3045 seconds long, membranes may rupture Active labor - answer-Anxiety and focus increase, 4-7cm, fetal descent, change of cervix is about 1cm/hr, contractions are 45-60 seconds long, they are strong Transition phase - answer-May demonstrate acute awareness for the need to focus on the task at hand, may feel out of control, tired, contractions are 1-2 min apart, 60-90 seconds long, 8-10 cm, usually lasts no more than 3 hours Second stage of labor - answer-Complete cervical dilation, descent of the fetus to the perineal floor, urge to push, crowing occurs Third stage of labor - answer-Birth to completed delivery of placenta Fourth stage of labor: - answer-1-4 hours post partum, monitoring for hemostasis, frequent uterine checks to ensure uterine contractions Average blood loss for vaginal delivery - answer-250-500 ml Average blood loss for C-section - answer-Up to 1000 mls Vaginal delivery - answer-Perineal stretching, shorter recovery time 4-6 weeks, ambulatory within 2-3 hours of delivery C-section - answer-Can be emergent or planned, longer recovery 6-8 weeks, not ambulatory until 4-12 hours after delivery, greater levels of discomfort, lifting restriction of 20-25 lbs First degree tear - answer-Skin around vaginal opening, may not need stitches Second degree tear - answer-Vaginal tissue, perineal muscle, stiches 4 weeks of healing usually Third degree tear - answer-Vaginal tissue, perineal muscle, muscle surrounding the anus, stitching, months to heal Fourth degree tear - answer-Most sever, perineal muscles and sphincter as well as tissue lining the rectum, months to heal, may end reconstructive surgery for incontinence, painful intercourse VEAL CHOP - answer-Variable deceleration—->cord compression Early Deceleration——> head compression Acceleration——> okay Late deceleration—-> poor placental perfusion Variable deceleration is caused by - answer-Cord compression Early deceleration is caused by - answer-Head compression Accelerations are - answer-Okay Late decelerations are caused by - answer-Poor placental perfusion Preterm labor need to know - answer--Before 37 weeks -Nifedipine: calcium channel blocker that is used to suppress contractions -mag sulfate: relaxes uterine activity -terbutaline:relaxes muscles and is an injection -Indomethacin: blocks prostaglandins (suppresses contractions) -Betamethasone: enhances fetal lug maturity -TB, diabetes, sickle cell, AI diseases, herpes, toxoplasmosis, and being young or old puts you at risk Ectopic pregnancy need to know - answer--when an ovum plants itself outside of the uterus -diagnosis can be challenging because many are asymptomatic until tubal rupture -Methotrexate: inhibits cell division -Prostaglandin: softens cervix -Misoprostol: stimulates uterine contractions to terminate pregnancy -most common in women from 35-44 -more common with those using IUD or new plan on Molar pregnancy - answer--not a viable pregnancy -no amniotic fluid or low amniotic fluid -thick cystic placenta nearly filling uterus -diagnose at 8-9 weeks -terminate ASAP with suction and curettage Placenta Previa - answer--when the placenta covers the opening of the mothers uterus -it usually presents with painless vaginal bleeding -increases probability with the more c-sections had If constipation is a problem for a woman during pregnancy, which measure would be best to recommend? - answer-Increased fiber intake A woman asks the nurse if she can take an over-the-counter vitamin during pregnancy rather than her prescription prenatal vitamin. A chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition is: - answer-Folic acid- it is added at a higher rate to prenatal vitamins A woman in her third trimester is suffering from heartburn. What should the nurse advise her to do? - answer-Eat small meals frequently rather than large meals. A pregnant client is excited that she is beginning to feel her baby move within her. The nurse explains that these first fetal movements are known as: - answer-Quickening A nurse is caring for an antenatal client diagnosed with umbilical cord prolapse. For which condition should the nurse monitor the fetus? - answer-Hypoxia- it is the fetus's only lifeline, and perfusion deteriorates rapidly A nurse urges a pregnant client at the first prenatal office visit to begin taking iron supplements immediately. What is the rationale for this intervention? - answer-To avoid anemia- the increase of the mothers blood circulation requires an extra 400 mg of iron a day A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider? - answer-Respiratory depression, hypotension, absent tendon reflexes- mag sulfate is a smooth muscle relaxant, this can cause respiratory depression and severe hypotension A primapara woman, 30 weeks' gestation, has no family support and frequently calls the health care provider's office with questions. Which report by the woman would alert the nurse that she may be having a complication related to the pregnancy and needs to come to the clinic today for further assessment? - answer-feeling of achy, cramping in vaginal area accompanied by bleeding that has saturated 1 pad/hour- the mother should report vaginal bleeding no matter how much The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? - answer-Increasing fluid intake- it helps relieve constipation by drinking at least 8 glasses of uncaffeinated beverages You care for a woman in a prenatal clinic who thinks she might be pregnant. Which of the following assessments is a probable sign of pregnancy? - answer-A positive pregnancy test- it is probable because mistakes can happen in the lab A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating? - answer-Preterm labor- regular contractions, cervical dilation and effacement, before 37 weeks A client comes to the emergency department reporting strong contractions that have lasted for the past 2 hours. Which assessment will indicate to the nurse that the client is in true labor? - answer-Progressive cervical dilation and effacement- regular uterine contractions cause progressive cervical dilation and effacement. During their experience in labor & delivery, a group of nursing students are observing a woman who is having uncoordinated contractions where the monitor shows some contractions close together, followed by a long period without any contractions. The nurse asks the students, "Which medication may help to stimulate a more effective, consistent pattern of contractions?" Which medication would be considered the best answer? - answer-Oxytocin- it could be helpful to stimulate more effective and consistent patterns of contractions Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? - answer-rupture of amniotic membranes-rupture of amniotic membranes is the best indicator of approaching labor The nurse is caring for a client in active labor who states, "I need to go to the bathroom to have a bowel movement, now." Which action should the nurse take first? - answer-Position the client for and perform a cervical assessment.- the urge to bear down comes with progression of labor, sign that dilation may be complete and the nurse needs to know if the pt is ready to start the labor process Which description is best when documenting an accurate client contraction? - answer-The client's contractions are 5 minutes apart and last 45 seconds- it includes no subjective data and has all needed info A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal? - answer-clear- it should be clear and smell slightly sweet A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement - answer-Provide emotional and physical support- when pain reaches an uncopable level she may need medication to help After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: - answer-assess the rate of flow of the oxytocin infusion.-A toxic effect of oxytoci'n therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms. A pregnant client has come to the labor and birth suite in labor. The nurse reviews the client's medical record and determines that a vaginal birth is favorable based on which finding related to the client's pelvic shape? - answer-gynecoid- the inlet is round and the outlet is roomy The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention - answer-Maternal tachycardia and falling blood pressure- this may indicate fluid volume deficit or hemorrhage A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth? - answer-McRoberts maneuver- frequently successful and often tried first, goes into lithotomy position, opens the pelvis to its widest diameter A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time? - answer-Push with contractions and rest between them. A woman whose fetus is in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? - answer-applying counterpressure to the back- applied pressure to the lower back with a fisted Hand sometimes helps cope with pain The nurse is caring for a client with a G=5, T=0, P=3, A=1, L=3 obstetric history. The nurse is most correct to state which interpretation? - answer-The client has had difficulty reaching full term. Which two tests are generally performed on urine at a prenatal visit? - answer-protein and glucose A client is 20' weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client? - answer-The client has pink vaginal discharge and pelvic pressure.- often the first symptom of dial action is pink discharge or increased pelvic pressure Which condition is the most common cause of anemia in pregnancy? - answer-iron deficiency anemia- the increased blood flow in the mother requires more iron Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? - answer-Turn off the pitocin. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion. A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? - answer-decrease in circulation and perfusion to the fetus-vital for the babes survival The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? - answer-duration The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: - answer-baseline FHR.-The baseline FHR averages 110 to 160 beats per minute over a 10-minute period.. A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed? - answer-tocolytic therapy- this is used to suppress preterm labor Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy? - answer-abdominal pain, vaginal bleeding, and a positive pregnancy test- nausea and vomiting may occur before rupture, but significantly increase after rupture A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? - answer-Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative- at risk of developing chorionic carcinoma, hCG levels not returning to normal is a sign the carcinoma is developing A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect? - answer-gestational trophoblastic disease- also known as "molar pregnancy" signs of this are nausea, vomiting, and dark brown vaginal discharge A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination, there is an elevated human chorionic gonadotropin (hCG) level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition? - answer-gestational trophoblastic disease- brownish vaginal bleeding along with above details are a sign of a molar pregnancy A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? - answer-"knife-like" abdominal pain with vaginal bleeding- note the bleeding will be dark red A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements? - answer-gestational hypertension- most common complication, shows no other signs related to hypertension just the high blood pressure A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? - answer-Palpate the fundus and check fetal heart rate- signs of abruptio placenta are pain, dark red vaginal bleeding, rigid abdomen, hypertonic labor, and fetal distress When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? - answer-prolonged decelerations- associated with prolonged cord compression, placental abruption, cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture A woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse suspect? - answer-uterine rupture- it should be suspected if a pregnant woman has experienced blunt trauma The nurse is admitting a client with a suspected diagnosis of abruptio placentae. Which assessment data would require the nurse to notify the healthcare provider immediately?. - answer-Overt vaginal bleeding, rigid abdomen, decreased blood pressure, increased heart rate- all signs of abruptio placental A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission? - answer-assessing fetal heart tones by use of an external monitor- don't disrupt the placenta, internal monitors, vaginal examination, and walking could all disrupt the placenta What would be the physiologic basis for a placenta previa - answer-low placental implantation- this is when the placenta blocks the uterine opening A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time? - answer-Fetal heart rate of 80 beats/minute- this is way too low and requires immediate attention A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? - answer-Change the client's position- variable indicates compression of the cord, this can be alleviated by changing positions of the mother A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: - answer-Lightening- this is when the baby moves lower in the pelvic region A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client is not in labor. Which nursing intervention should the nurse perform? - answer-Monitor the amount of vaginal blood loss- need to keep track of the blood loss and vitals, no ambulating, no vaginal examination, keep risks at a low Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? - answer-vaginal examination- no vaginal examination until placenta previa is ruled out A client in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history, what should the nurse suspect? - answer-placenta previa- bright red bleeding, no pain, all signs of placenta previa What action(s) does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply. - answer-Assigning apgar scores, drying newborn, initiating skin to skin, taking newborn vital signs-waiting on the placenta, need to complete all duties we can until that happens The nurse is measuring the fundal height of a woman who is at 28 weeks' gestation. Which measurement would the nurse expect? - answer-28 cm-fundal height should roughly align with the weeks of gestation When evaluating a pregnant client's fundal height, the nurse should measure in which way? - answer-From the symphysis pubis notch to the highest level of the fundus A nurse at the health care facility assesses a client at 20 weeks' gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client? - answer-At the level of the umbilicus The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby? - answer-1 cm below ischial spine A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? - answer-Assess fetal heart sounds.-rule out cord prolapse make sure the fetal heart sounds are normal A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement? - answer-Change maternal position to an upright or side lying position.- poor placental perfusion, changing positions helps improve the maternal venous return A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? - answer-Early decelerations- the head is being compressed during the contractions, it is not fetal distress A client has just received combined spinal epidural. Which nursing assessment should be performed first - answer-Assess vital signs.- need a before epidural baseline and post epidural baseline The nurse would prepare a client for amnioinfusion when which action occurs? - answer-Severe variable decelerations occur and are due to cord compression. The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply. - answer-IV hydration, maternal position change, oxygen administration- IV increases blood volume and flow to the uterus, position changes can also improve uterine blood flow, administering oxygen can raise the mothers oxygen level increasing the amount given to baby In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion? - answer-Fetal heart rate accelerations- shows that everything is going well and the baby is oxygenated and happy The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? - answer-late decelerations, the fetas is being deprived of oxygen The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? - answer-uteroplacental insufficiency- late decelerations= poor placental perfusion A nursing student correctly identifies the most desirable position to promote an easy birth as which position? - answer-occiput anterior- (face down ass up) hahaha have a funny while you study and a easy remembering tool 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? - answer-Occiput posterior position- sunny side up What term is used to describe the position of the fetal long axis in relation to the long axis of the mother - answer-fetal lie- how the baby is "lying" in the mother A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? - answer-umbilical cord prolapse- urgent, needs attention right away A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? - answer-ROA- r=right o=ocuput a=anterior The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: - answer-left lower quadrant- want to do it on the fetal back Which method does the nurse use to determine fetal presentation, position, and attitude? - answer-Utilize Leopold maneuvers- feeling for the fetal back and limbs by palpating (when bailey was the mother in class and Ashley felt for the baby) Abruptio placentae - answer-Early separation of a normal implanted lace at after the 20th week of gestation. -prognosis is a 40% fetal morality rate -5% maternal mortality rate -severe abdominal pain, vaginal bleeding, usually dark -rigid abdomen/uterus Umbilical cord prolapse - answer-Protrusion of the umbilical cord alongside or ahead of the presenting part of the fetus -poor perfusion from the placenta occurs -DO NOT reinsert the cord -EMERGENCY C-SECTION