Question 6011)
A client's membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?
A. Auscultate the FHR.
B. Time the contractions.
C. Call the health care provider.
D. Obtain the maternal vital signs.
Answer: A
Explanation: When the membranes rupture, there is always the possibility of a prolapsed cord leading to fetal compromise, which will manifest itself in a slow FHR.
Question 6012)
A client is admitted to the birthing unit in active labor. What should the nurse expect after an amniotomy is performed?
A. Diminished bloody show
B. Increased and more variable FHR
C. Less discomfort with contractions
D. Progressive dilation and effacement
Answer: D
Explanation: Artificial rupture of the membranes (amniotomy) allows for more effective pressure of the fetal head on the cervix, enhancing dilation and effacement.
Question 6013) Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor?
A. The mechanical and chemical digestive processes require energy that is needed for labor.
B. Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia.
C. The gastric phase of digestion stimulates the release of hydrochloric acid and may cause dyspesia.
D. Food and fluid will further aggravate gastric peristalsis, which is already increased because of the stress of labor.
Answer: B
Explanation: Gastric peristalsis often ceases during periods of stress. Abdominal contractions put pressure on the stomach and can cause nausea and vomiting, increasing the risk for aspiration.
Question 6014) When a client's legs are placed in stirrups for birth, the nurse confirms that both legs are positioned simultaneously to prevent:
A. venous stasis in the legs.
B. pressure on the perineum.
C. excessive pull on the fascia.
D. trauma to the uterine ligaments.
Answer: D
Explanation: As the uterus rises into the abdominal cavity, the uterine ligaments become elongated and hypertrophied, raising both legs at the same time limits the tension placed on these ligaments.
Question 6015) A laboring client is to have a pudendal block. What should a nurse teach the client about the effects of the pudendal block?
A. Bladder sensation may be lost.
B. She will not feel an episiotomy.
C. She may lose the ability to push.
D. Contractions will no longer be felt.
Answer: B
Explanation: A pudendal block provides anesthesia to the perineum.
Question 6016)
A primigravida who is at 35 weeks gestation is diagnosed with hydraminos. For what should the nurse assess the newborn?
A. Cardiac defect
B. Kidney disorder
C. Diabetes mellitus
D. Esophageal atresia
Answer: D
Explanation: Esophageal atresia is associated with hydramnios.
Question 6017)
A nurse examines a client who had a cesarean birth. It is 3 days since the birth and the client is about to be discharged. Where does the nurse expect the fundus to be located?
A. 1 finger breadth below the umbilicus
B. 2 finger breadth below the umbilicus
C. 3 finger breadth below the umbilicus
D. 4 finger breadth below the umbilicus
Answer: C
Explanation: The fundus descends one finger breadth per day from the first postpartum day.
Question 6018)
A nurse is caring for a postpartum client who is formula feeding. What should the nurse teach her about minimizing breast discomfort?
A. Apply covered ice packs to her breasts.
B. Gently apply cocoa butter to her nipples.
C. Place warm, wet washcloths on her nipples.
D. Manually express colostrum from her breasts.
Answer: A
Explanation: Covered ice packs promote comfort by decreasing vasocongestion.
Question 6019)
A teenager at 32 weeks gestation is hospitalized with preeclampsia. She is anorexic and appears depressed. Which comment indicates to the nurse that further exploration of the client's emotional status is indicated.
A. "I'm tired of feeling so clumsy."
B. "I'll be glad when I can sleep all night."
C. "I dreamed my baby had only one arm."
D. "I was really happy before I got pregnant."
Answer: D
Explanation: This indicates failure to resolve conflicting feelings about pregnancy that should have been resolved in the first trimester.
Question 6020)
A client at 38 weeks gestation is admitted for induction of labor. Her membranes ruptured 12 hours ago. There are no other signs of labor. Which medication does the nurse anticipate will be prescribed?
A. Oxytocin (Pitocin)
B. Estrogen (Premarin)
C. Ergonovine (Ergotrate)
D. Progesterone (Prometrium)
Answer: A
Explanation: Oxytocin (Pitocin) is a small polypeptide hormone synthesized in the hypothalamus and secreted from the neurohypophysis (posterior pituitary gland) during parturition or suckling, it promotes powerful uterine contractions and thus is used to induce labor.
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