Maternal-Newborn chapter 15 test bank updated 2024-2025, Exams of Nursing

Download Maternal-Newborn chapter 15 test bank updated 2024-2025 and more Exams Nursing in PDF only on Docsity! Maternal-Newborn chapter 15 test bank updated 2024-2025 Which comfort measure should the nurse utilize a laboring woman to relax? A: recommend frequent position changes B: palpate her filling bladder every 15 minutes C: offer warm wet cloths to use on the client's face and neck D: keep the room lights lit so the client and her coach can see everything - correct answer ☑ ☑ A: recommend frequent position changes Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor become very hot and perspire. Cool cloths will provide greater relief. Soft indirect lighting is more soothing than irritating bright lights. Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient? A: elevated pulse rate B: elevated blood pressure Maternal-Newborn chapter 15 test bank updated 2024-2025 C: firm funds at the midline D: saturation of two perineal pads in 4 hours - correct answer ☑ ☑ A: elevated pulse rate An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits. Which intervention is an essential part of nursing care for a laboring patient? A: helping the woman manage the pain B: eliminating the pain associated with labor C: feeling comfortable with the predictable nature of intrapartal care D: sharing personal experiences regarding labor and birth to decrease her anxiety - correct answer ☑ ☑ A: helping the woman manage the pain Maternal-Newborn chapter 15 test bank updated 2024-2025 been normal. Contractions are 5-9 minutes apart, 20-30 seconds in duration, and of mild intensity. Cervical dilation is 1-2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the patient to be: A: discharged home with a sedative B: admitted for extended observation C: admitted and prepared for a cesarean birth D: discharged home to await the onset of true labor - correct answer ☑ ☑ D: discharged home to await the onset of true labor The situation describes a patient with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The patient will probably be discharged, and there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated. Maternal-Newborn chapter 15 test bank updated 2024-2025 The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing interventions is most appropriate at this time? A: inform the mother that the fetal heart rate is normal B: reassess the fetal heart rate in 5 minutes because the rate is too high C: report the fetal heart rate to the physician or nurse- midwife immediately D: suggest to the mother that she is going to have a boy because the heart rate is fast - correct answer ☑ ☑ A: inform the mother that the fetal heart rate is normal The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR. Which clinical finding would be an indication to the nurse that the fetus may be compromised? A: active fetal movements Maternal-Newborn chapter 15 test bank updated 2024-2025 B: fetal heart rate in the 140s C: contractions lasting 90 seconds D: meconium-stained amniotic fluid - correct answer ☑ ☑ D: meconium-stained amniotic fluid When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate? A: every 15 minutes B: every 30 minutes C: every 45 minutes D: every 1 hour - correct answer ☑ ☑ B: every 30 minutes Maternal-Newborn chapter 15 test bank updated 2024-2025 A: a sign of abnormal labor progress B: an indication that she needs analgesia C: normal and related to hyperventilation D: common during the transition phase of labor - correct answer ☑ ☑ D: common during the transition phase of labor The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis. The nurse thoroughly dries the infant immediately after birth primarily to: A: reduce heat loss from evaporation B: stimulate crying and lung expansion C: increase blood supply to the hands and feet Maternal-Newborn chapter 15 test bank updated 2024-2025 D: remove maternal blood from the skin surface - correct answer ☑ ☑ A: reduce heat loss from evaporation Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood. The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? A: request a social service consult for psychosocial support B: observe for other signs that the mother may not be accepting of the infant C: document this evidence of normal early maternal- infant attachment behavior D: determine whether the mother is too fatigues to interact normally with her infant - correct answer ☑ ☑ C: document this evidence of normal early maternal-infant attachment behavior Maternal-Newborn chapter 15 test bank updated 2024-2025 Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high- pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner. Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours. A: fluid volume deficit (FVD) related to fluid loss during labor and birth process B: fatigue related to length of labor requiring increased energy expenditure C: acute pain related to increased intensity of contractions D: anxiety related to imminent birth process - correct answer ☑ ☑ D: anxiety related to imminent birth process Maternal-Newborn chapter 15 test bank updated 2024-2025 Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul- smelling fluid suggests infection. Bloody fluid may indicate partial placental separation. The nurse is preparing to initiate IV access on a patient in the active phase of labor. Which IV cannula is best for this patient? A: 18-gauge B: 20-gauge C: 22-gauge D: 24-gauge - correct answer ☑ ☑ A: 18-gauge The nurse should select the largest bore cannula possible. An 18-gauge cannula is the largest size available. A 24- gauge cannula would be the smallest. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula. Maternal-Newborn chapter 15 test bank updated 2024-2025 While assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider? A: maternal pulse rate of 100 bpm B: maternal blood pressure of 120/70 mm Hg C: persistent fetal bradycardia below 100 bpm D: decreased intensity of uterine contractions - correct answer ☑ ☑ C: persistent fetal bradycardia below 100 bpm Fetal bradycardia may indicate fetal distress and may require immediate intervention. Maternal pulse rate may increase due to the pushing process. Blood pressure of 120/70 mm Hg is within expected norms for this stage of labor. Decreased intensity of uterine contractions indicates the birth is imminent at this point. The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric provider? A: to determine the status of the membranes Maternal-Newborn chapter 15 test bank updated 2024-2025 B: to determine cervical dilation and effacement C: to determine the best location to assess the fetal heart rate D: to determine whether the fetus is in the posterior position - correct answer ☑ ☑ C: to determine the best location to assess the fetal heart rate Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A pH test or fern test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination. A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include: A: contraction pattern, amount of discomfort, and pregnancy history B: fetal heart rate, maternal vital signs, and the woman's nearness to birth C: last food intake, when labor began, and cultural practices the couple desires Maternal-Newborn chapter 15 test bank updated 2024-2025 The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding. A nursing priority during admission of a laboring patient who has not had prenatal care is: A: obtaining admission labs B: identifying labor risk factors C: discussing her birth plan choices D: explaining importance of prenatal care - correct answer ☑ ☑ B: identifying labor risk factors When a patient has not had prenatal care, the nurse must determine through interviewing and examination the Maternal-Newborn chapter 15 test bank updated 2024-2025 presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed. The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record? A: fetal heart rate B: pain level C: test results ensuring that the fluid is not urine D: the patient's understanding of the event - correct answer ☑ ☑ A: fetal heart rate Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The patient's understanding of the event would only need to be documented if it presents a problem. Maternal-Newborn chapter 15 test bank updated 2024-2025 For which patient should oxytocin (Pitocin) infusion be discontinued immediately? A: a patient in transition with contractions every 2 minutes lasting 90 seconds each B: a patient in early labor with contractions every 5 minutes lasting 40 seconds each C: a patient in active labor with contractions every 3 minutes lasting 60 seconds each D: a patient in active labor with contractions every 2-3 minutes lasting 70-80 seconds each - correct answer ☑ ☑ A: a patient in transition with contractions every 2 minutes lasting 90 seconds each This patient's contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this patient's contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this patient's contractions. There is an appropriate resting period between this patient's contractions for her stage of labor.