TEST 2 (Chapters 8, 9, 10, 12, 13, 14) maternity
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What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. Maternal temperature is 37.8 C - (correct Answer) - C
Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated
with fetal compromise.
A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and
begins to have contractions every 90 seconds. What is the nurses initial action?
a. Stop the oxytocin infusion.
b. Continue the infusion and report the findings to the physician.
c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask. - (correct
Answer) - A
Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.
What nursing care should be provided to a woman with a third-degree laceration immediately after
delivery?
a. Warm compresses to the perineum
b. Cold pack to the perineum
c. Warm sitz bath
d. Elevation of hips to prevent edema - (correct Answer) - B
Ice is applied to the perineum to reduce bruising and edema.
After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but
,contractions are becoming shorter and less frequent. What is this labor pattern considered?
a. Normal
b. Hypotonic
c. Hypertonic d. False - (correct Answer) - B
The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but
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Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 71
contractions diminish after the active phase.
A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with
membranes intact. What action by the physician will the nurse anticipate?
a. Perform an amniotomy.
b. Initiate tocolytic drugs.
c. Order a sedative for the patient.
d. Plan to do an emergency cesarean section. - (correct Answer) - A
Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the
membranes are intact.
An infant is delivered with the use of forceps. What should the nurse assess for in the newborn?
a. Loss of hair from contact with forceps
b. Sacral hematoma
c. Facial asymmetry
d. Shoulder dislocation - (correct Answer) - C
Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry.
A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle.
The nurse responds, This condition will resolve itself in a few days. What is the cause?
a. Prolonged pressure against the partially dilated cervix
,b. Small leak of fluid through the posterior fontanelle
c. Pressure of the forceps during delivery d. The effect of the vacuum extractor - (correct Answer) - D
The chignon is due to the effect of the vacuum extractor and will disappear in a few days.
A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor
wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I
need? What is the lowest Bishop score the patient should have prior to induction?
a. 6
b. 8
c. 10
d. 12 - (correct Answer) - A
The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is
recommended by the American Congress of Obstetricians and Gynecologists (ACOG).
A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP).
What position will the nurse promote to encourage fetal rotation and pain relief?
a. Prone with legs supported and give her a back massage
b. Supine with legs bent at the knee
c. Standing with support
d. Sitting up and leaning forward on the over-bed table - (correct Answer) - D
A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to
sit or kneel leaning forward on a support.
The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9
cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain
relief intervention for a woman in precipitate labor?
a. Get an order for an intravenous narcotic.
b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions.
d. Tell her to bear with it because she is close to delivery - (correct Answer) - C
The nurse would stay with the woman experiencing precipitate labor and breathe with her during
contractions to help the woman focus and cope with each contraction.
A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured
spontaneously. What complication should the nurse closely assess for with this patient?
a. Chorioamnionitis
, b. Hemorrhage
c. Hypotension
d. Amniotic fluid embolism - (correct Answer) - A
Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it
may be a consequence of rupture because the barrier to the uterine cavity is broken.
The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The
nurse would assess for which adverse effect?
a. Maternal tachycardia
b. Maternal hypertension
c. Fetal bradycardia
d. Fetal hypokalemia - (correct Answer) - A
Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with
a dose of propranolol.
Which statement indicates a woman understands activity limitations for the management of preterm
labor?
a. After my shower in the morning, I do the laundry and straighten up the house; then I rest.
b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.
c. I have a 2-year-old to care for, but I try to rest as much as I can.
d. I get really bored at home, so I go to the shopping mall for just a little while. - (correct Answer) - B
Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman
identify ways to organize necessary activities and maximize rest.
A student nurse questions the instructor regarding what alteration should be made for the assessment of
the fundus of a new postoperative cesarean section patient. What is the best response?
a. The fundus is not assessed until the second postoperative day.
b. The fundus is assessed by walking fingers from the side of the uterus to the midline.
c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every
shift. - (correct Answer) - B
Assessment of the fundus following a cesarean section is done as usual, but using especially gentle
fundal massage.
A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse
position the woman to prevent compression of a prolapsed cord?
Save
What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. Maternal temperature is 37.8 C - (correct Answer) - C
Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated
with fetal compromise.
A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and
begins to have contractions every 90 seconds. What is the nurses initial action?
a. Stop the oxytocin infusion.
b. Continue the infusion and report the findings to the physician.
c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask. - (correct
Answer) - A
Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.
What nursing care should be provided to a woman with a third-degree laceration immediately after
delivery?
a. Warm compresses to the perineum
b. Cold pack to the perineum
c. Warm sitz bath
d. Elevation of hips to prevent edema - (correct Answer) - B
Ice is applied to the perineum to reduce bruising and edema.
After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but
,contractions are becoming shorter and less frequent. What is this labor pattern considered?
a. Normal
b. Hypotonic
c. Hypertonic d. False - (correct Answer) - B
The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but
NURSINGTB.COM
NURSINGTB.COM
INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 71
contractions diminish after the active phase.
A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with
membranes intact. What action by the physician will the nurse anticipate?
a. Perform an amniotomy.
b. Initiate tocolytic drugs.
c. Order a sedative for the patient.
d. Plan to do an emergency cesarean section. - (correct Answer) - A
Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the
membranes are intact.
An infant is delivered with the use of forceps. What should the nurse assess for in the newborn?
a. Loss of hair from contact with forceps
b. Sacral hematoma
c. Facial asymmetry
d. Shoulder dislocation - (correct Answer) - C
Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry.
A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle.
The nurse responds, This condition will resolve itself in a few days. What is the cause?
a. Prolonged pressure against the partially dilated cervix
,b. Small leak of fluid through the posterior fontanelle
c. Pressure of the forceps during delivery d. The effect of the vacuum extractor - (correct Answer) - D
The chignon is due to the effect of the vacuum extractor and will disappear in a few days.
A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor
wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I
need? What is the lowest Bishop score the patient should have prior to induction?
a. 6
b. 8
c. 10
d. 12 - (correct Answer) - A
The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is
recommended by the American Congress of Obstetricians and Gynecologists (ACOG).
A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP).
What position will the nurse promote to encourage fetal rotation and pain relief?
a. Prone with legs supported and give her a back massage
b. Supine with legs bent at the knee
c. Standing with support
d. Sitting up and leaning forward on the over-bed table - (correct Answer) - D
A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to
sit or kneel leaning forward on a support.
The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9
cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain
relief intervention for a woman in precipitate labor?
a. Get an order for an intravenous narcotic.
b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions.
d. Tell her to bear with it because she is close to delivery - (correct Answer) - C
The nurse would stay with the woman experiencing precipitate labor and breathe with her during
contractions to help the woman focus and cope with each contraction.
A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured
spontaneously. What complication should the nurse closely assess for with this patient?
a. Chorioamnionitis
, b. Hemorrhage
c. Hypotension
d. Amniotic fluid embolism - (correct Answer) - A
Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it
may be a consequence of rupture because the barrier to the uterine cavity is broken.
The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The
nurse would assess for which adverse effect?
a. Maternal tachycardia
b. Maternal hypertension
c. Fetal bradycardia
d. Fetal hypokalemia - (correct Answer) - A
Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with
a dose of propranolol.
Which statement indicates a woman understands activity limitations for the management of preterm
labor?
a. After my shower in the morning, I do the laundry and straighten up the house; then I rest.
b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.
c. I have a 2-year-old to care for, but I try to rest as much as I can.
d. I get really bored at home, so I go to the shopping mall for just a little while. - (correct Answer) - B
Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman
identify ways to organize necessary activities and maximize rest.
A student nurse questions the instructor regarding what alteration should be made for the assessment of
the fundus of a new postoperative cesarean section patient. What is the best response?
a. The fundus is not assessed until the second postoperative day.
b. The fundus is assessed by walking fingers from the side of the uterus to the midline.
c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every
shift. - (correct Answer) - B
Assessment of the fundus following a cesarean section is done as usual, but using especially gentle
fundal massage.
A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse
position the woman to prevent compression of a prolapsed cord?
