Maternity Exam with Complete Solutions
What is the optimal nursing intervention to minimize perineal edema after an episiotomy?
Applying ice packs Correct Ans-Cold causes vasoconstriction and reduces edema by
lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens
nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema.
Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage.
Elevating the hips provides minimal perineal relief.
A client in active labor has requested epidural anesthesia for pain management . The
anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid
bolus. The client's partner asks why this is necessary. What is the best explanation?
There is a risk of hypotension, & the large amount of IV fluid reduces this risk. Correct Ans-
Once an epidural is initiated there is a risk of hypotension (low blood pressure), which may
result in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural
medication is administered through a catheter placed by the anesthetist. Quoting institutional
policy does not provide the explanation for administering the solution. Providing 500 mL of
fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of
determining that the line is patent before the administration of medication.
, Maternity Exam with Complete Solutions
As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns
pale and states that she feels as if she is going to faint even though she is lying flat on her
back. What is the nurse's priority intervention?
Turn her onto her left side Correct Ans-The client is experiencing supine hypotension,
which is caused by compression of the large vessels by the gravid uterus. A side-lying position
will relieve the pressure on the vessels, increase venous return, improve cardiac output, and
increase blood pressure.
S/S: Pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, sweating.
Interventions: position woman on her side until s/s subside & vital signs stabilize within
normal limits.
A client is admitted to the birthing unit in active labor. Which physiologic changes should the
nurse anticipate after an amniotomy is performed?
, Maternity Exam with Complete Solutions
Progressive dilation & effacement Correct Ans-Artificial rupture of the membranes
(amniotomy) allows more effective exertion of pressure of the fetal head on the cervix,
enhancing dilation and effacement. Vaginal bleeding may increase because of the progression
of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become
greater because contractions usually increase in intensity and frequency after the membranes
are artificially ruptured.
During the second stage of labor the nurse discourages the client from holding her breath
longer than 6 seconds while pushing with each contraction. Which complication does this
prevent?
Fetal hypoxia Correct Ans-Prolonged breath holding at this stage of labor can result in
decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations
occur with rapid, uncontrolled expulsion of the fetus.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What
stage of labor does the nurse record?
First Correct Ans-The first stage of labor is from zero cervical dilation to full cervical
dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal
What is the optimal nursing intervention to minimize perineal edema after an episiotomy?
Applying ice packs Correct Ans-Cold causes vasoconstriction and reduces edema by
lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens
nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema.
Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage.
Elevating the hips provides minimal perineal relief.
A client in active labor has requested epidural anesthesia for pain management . The
anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid
bolus. The client's partner asks why this is necessary. What is the best explanation?
There is a risk of hypotension, & the large amount of IV fluid reduces this risk. Correct Ans-
Once an epidural is initiated there is a risk of hypotension (low blood pressure), which may
result in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural
medication is administered through a catheter placed by the anesthetist. Quoting institutional
policy does not provide the explanation for administering the solution. Providing 500 mL of
fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of
determining that the line is patent before the administration of medication.
, Maternity Exam with Complete Solutions
As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns
pale and states that she feels as if she is going to faint even though she is lying flat on her
back. What is the nurse's priority intervention?
Turn her onto her left side Correct Ans-The client is experiencing supine hypotension,
which is caused by compression of the large vessels by the gravid uterus. A side-lying position
will relieve the pressure on the vessels, increase venous return, improve cardiac output, and
increase blood pressure.
S/S: Pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, sweating.
Interventions: position woman on her side until s/s subside & vital signs stabilize within
normal limits.
A client is admitted to the birthing unit in active labor. Which physiologic changes should the
nurse anticipate after an amniotomy is performed?
, Maternity Exam with Complete Solutions
Progressive dilation & effacement Correct Ans-Artificial rupture of the membranes
(amniotomy) allows more effective exertion of pressure of the fetal head on the cervix,
enhancing dilation and effacement. Vaginal bleeding may increase because of the progression
of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become
greater because contractions usually increase in intensity and frequency after the membranes
are artificially ruptured.
During the second stage of labor the nurse discourages the client from holding her breath
longer than 6 seconds while pushing with each contraction. Which complication does this
prevent?
Fetal hypoxia Correct Ans-Prolonged breath holding at this stage of labor can result in
decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations
occur with rapid, uncontrolled expulsion of the fetus.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What
stage of labor does the nurse record?
First Correct Ans-The first stage of labor is from zero cervical dilation to full cervical
dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal
