Maternity Nursing 8th ed By Lowdermilk, Perry, Cashion -Test Bank

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Maternity Nursing 8th ed By Lowdermilk, Perry, Cashion -Test Bank

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Maternity Nursing 8th ed By Lowdermilk, Perry, Cashion -Test Bank

Lowdermilk: Maternity Nursing, 8th Edition

 

Chapter 02: Assessment and Health Promotion

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The two primary functions of the ovary are:
a. Normal female development and sex hormone release.
b. Ovulation and internal pelvic support.
c. Sexual response and ovulation.
d. Ovulation and hormone production.

 

ANS: D

 

  Feedback
A The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen.
B Ovulation is the release of a mature ovum from the ovary; the ovaries are not responsible for internal pelvic support.
C Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the ovaries. Ovulation does occur in the ovaries.
D The two functions of the ovaries are ovulation and hormone production.

 

DIF:   Cognitive Level: Knowledge        REF:  28

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Assessment

 

  1. Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is:
a. Five to 7 days after menses ceases.
b. Day 1 of the endometrial cycle.
c. Midmenstrual cycle.
d. Any time during a shower or bath.

 

ANS: A

 

  Feedback
A The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after menstruation stops. Therefore BSE is best performed during this phase of the menstrual cycle.
B All women should perform BSE on a regular basis; however, the ideal time is when the breasts are not tender or swollen. This occurs at the end of menstruation.
C All women should perform BSE; however, the ideal time is 5 to 7 days after the menses ceases.
D The woman should be instructed that the best position for BSE is to lie down and place a pillow under the breast to be examined first.

 

DIF:   Cognitive Level: Knowledge        REF:  30

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

  1. Sexual assault is:
a. Limited to rape.
b. An act of force in which an unwanted and uncomfortable sexual act occurs.
c. A legal term for sexual violence.
d. An act of violence in which the partner is unknown.

 

ANS: B

 

  Feedback
A Sexual assault is a broad term that encompasses a wide range of sexual victimization. It may include but is not limited to rape.
B Sexual assault encompasses a wide range of sexual victimization, including unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual acts.
C Sexual violence is a term for rape, not sexual assault, that includes a broader range of activities.
D A sexual act of violence, or rape, may be categorized as sexual assault. Statistically, the victim knows the assailant.

 

DIF:   Cognitive Level: Comprehension  REF:  44

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

  1. Individual irregularities in the ovarian (menstrual) cycle are most often caused by:
a. Variations in the follicular (preovulatory) phase.
b. An intact hypothalamic-pituitary feedback mechanism.
c. A functioning corpus luteum.
d. A prolonged ischemic phase.

 

ANS: A

 

  Feedback
A Almost all variations in the length of the ovarian cycle are the result of variations in the length of the follicular phase.
B An intact hypothalamic-pituitary feedback mechanism is regular, not irregular.
C The luteal phase begins after ovulation. The corpus luteum depends on the ovulatory phase and fertilization.
D During the ischemic phase, the blood supply to the functional endometrium is blocked, and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins.

 

DIF:   Cognitive Level: Comprehension  REF:  34

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. Prostaglandins are produced in most organs of the body, most notably the endometrium. Another/Other source(s) of prostaglandins is/are:
a. Ovaries.
b. Breast milk.
c. Menstrual blood.
d. The vagina.

 

ANS: C

 

  Feedback
A Prostaglandins are produced in most organs of the body and in menstrual blood. The ovaries are not a source of prostaglandins.
B Prostaglandins are produced in most organs of the body and in menstrual blood. Breast milk is not a source of prostaglandins.
C Menstrual blood is a potent source of prostaglandins.
D Prostaglandins are produced in most organs of the body and in menstrual blood. The vagina is not a source of prostaglandins.

 

DIF:   Cognitive Level: Knowledge        REF:  34

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. Physiologically, sexual response can be characterized by:
a. Coitus, masturbation, and fantasy.
b. Myotonia and vasocongestion.
c. Erection and orgasm.
d. Excitement, plateau, and orgasm.

 

ANS: B

 

  Feedback
A Coitus, masturbation, and fantasy are forms of stimulation that illicit the physical manifestation of the sexual response.
B Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia.
C Erection and orgasm occur in two of the four phases of the sexual response cycle.
D Excitement, plateau, and orgasm are three of the four phases of the sexual response cycle.

DIF:   Cognitive Level: Knowledge        REF:  35

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. One purpose of preconception care is to:
a. Ensure that pregnancy complications do not occur.
b. Identify women who should not become pregnant.
c. Encourage healthy lifestyles for families desiring pregnancy.
d. Ensure that women know about prenatal care.

 

ANS: C

 

  Feedback
A Preconception care does not ensure that pregnancy complications will not occur. In many cases, problems can be identified and treated and may not recur in subsequent pregnancies.
B In many instances, counseling can allow behavior modification before damage is done, or a woman can make an informed decision about her willingness to accept potential hazards.
C Preconception counseling guides couples in how to avoid unintended pregnancies, how to identify and manage risk factors in their lives and their environment, and how to identify healthy behaviors that promote the well-being of the woman and her potential fetus.
D If a woman is seeking preconception care, she likely is aware of prenatal care.

 

DIF:   Cognitive Level: Comprehension  REF:  36

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

  1. Concerning the use and abuse of legal drugs or substances, nurses should be aware that:
a. Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health.
b. Women ages 21 to 34 have the highest rates of specific alcohol-related problems.
c. Coffee is a stimulant that can interrupt body functions and has been related to birth defects.
d. Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise they would not have been prescribed.

 

ANS: B

 

  Feedback
A Cigarette smoking impairs fertility and is a cause of low birth weight.
B Although a very small percentage of childbearing women have alcohol-related problems, alcohol abuse during pregnancy has been associated with a number of negative outcomes.
C Caffeine consumption has not been related to birth defects.
D Psychotherapeutic drugs have some effect on the fetus, and that risk must be weighed against their benefit to the mother.

 

DIF:   Cognitive Level: Knowledge        REF:  40

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

  1. During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurses first response should be to:
a. Advise the woman of mandatory state reporting laws pertaining to abuse and confidentiality.
b. Reassure the woman that the abuse is not her fault.
c. Give the woman referrals to local agencies and shelters where she can obtain help.
d. Formulate an escape plan for the woman that she can use the next time her husband abuses her.

 

ANS: A

 

  Feedback
A Many states have mandatory reporting laws for health care providers. It is important to inform the patient that you may need to report this.
B Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation.
C Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation.
D Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation.

 

DIF:   Cognitive Level: Application        REF:  45

OBJ:  Client Needs: Safe and Effective Care Environment    TOP:  Nursing Process: Planning

 

  1. As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm labor, premature separation of the placenta, and stillbirth?
a. Heroin
b. Alcohol
c. PCP
d. Cocaine

 

ANS: D

 

  Feedback
A Heroin is an opiate. Its use in pregnancy is associated with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor.
B The most serious effect of alcohol use in pregnancy is fetal alcohol syndrome.
C The major concerns regarding PCP use in pregnant women are its association with polydrug abuse and the neurobehavioral effects on the neonate.
D Cocaine is a powerful central nervous system stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth.

 

DIF:   Cognitive Level: Comprehension  REF:  40

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

  1. Kegel exercises, or pelvic muscle exercises:
a. Were developed to control or reduce incontinent urine loss.
b. Are the best exercises for a pregnant woman because they are so pleasurable.
c. Help to manage stress.
d. Are ineffective without sufficient calcium in the diet.

 

ANS: A

 

  Feedback
A Kegel exercises help control the urge to urinate.
B Kegel exercises may be fun for some, but the most important matter is the control they provide over incontinence.
C Kegel exercises help manage urination, not stress.
D Calcium in the diet is important but is not related to Kegel exercises.

 

DIF:   Cognitive Level: Knowledge        REF:  54

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

  1. During the past 20 years, the prevalence of obesity has increased dramatically in the United States, with one-third of women older than 20 years of age being obese. Body mass index is defined as the measure of an adults weight in relation to his or her height. This is currently the most accurate measure of weight. It is an important part of the health screening process because obesity is closely associated with:
a. The non-Hispanic Caucasian population.
b. A large number of chronic conditions.
c. Mostly acute illnesses.
d. Improved mental well-being.

 

ANS: B

 

 

  Feedback
A In the United States, the prevalence of obesity is highest among non-Hispanic black women, followed by Hispanic women and non-Hispanic Caucasian women.
B Overweight and obesity are known risk factors for diabetes, heart disease, dyslipidemia, stroke, hypertension, arthritis, osteoporosis, and some types of cancer.
C Overweight and obesity are most frequently linked to chronic conditions.
D This is a myth. In fact, obesity is associated with depression and increased stress.

 

DIF:   Cognitive Level: Knowledge        REF:  41

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. Before beginning the health history interview, the nurse should perform all actions except:
a. Smile and ask the patient whether she has any special concerns.
b. Speak in a relaxed manner with an even, nonjudgmental tone.
c. Make the patient comfortable.
d. Tell the patient her questions are irrelevant.

 

ANS: D

 

  Feedback
A This action is appropriate for the nurse to do before beginning the health history.
B This action is appropriate for the nurse to do before beginning the health history.
C This action is appropriate for the nurse to do before beginning the health history.
D The woman should be assured that all of her questions are relevant and important.

 

DIF:   Cognitive Level: Comprehension  REF:  44

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. During a health history interview, a woman states that she thinks that she has bumps on her labia. She also states that she is not sure how to check herself. The correct response would be to:
a. Reassure the woman that the examination will not reveal any problems.
b. Explain the process of vulvar self-examination to the woman and reassure her that she should become familiar with normal and abnormal findings during the examination.
c. Reassure the woman that bumps can be treated.
d. Reassure her that most women have bumps on their labia.

 

ANS: B

 

  Feedback
A This statement is not accurate.
B During the assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination.
C This statement is not accurate.
D This statement is not accurate.

 

DIF:   Cognitive Level: Application        REF:  50

OBJ:  Client Needs: Physiologic Integrity                                          TOP:   Nursing Process: Assessment

 

  1. Women with severe and persistent mental illness are likely to be more vulnerable to being involved in controlling and/or violent relationships. However, many women develop mental health problems as a result of long-term abuse. The psychologic consequences of continued abuse do not include:
a. Substance abuse.
b. Posttraumatic stress disorder (PTSD).
c. Eating disorders.
d. Bipolar disorder.

 

ANS: D

 

  Feedback
A Substance abuse is a common method of coping with long-term abuse. The abuser is also more likely to use alcohol and other chemical substances.
B PTSD is the most prevalent mental health sequela of long-term abuse. The traumatic event is persistently reexperienced through distress recollection and dreams.
C Eating disorders, depression, psychophysiologic illness, and anxiety reactions are all mental health problems associated with repeated abuse.
D Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to abuse.

 

DIF:   Cognitive Level: Analysis             REF:  44

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Diagnosis

 

  1. A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection and she has been using an over-the-counter cream for the past 2 days to treat it. The nurses initial response should be to:
a. Inform the woman that vaginal creams may interfere with the Papanicolaou (Pap) test for which she is scheduled.
b. Reassure the woman that using vaginal cream is not a problem for the examination.
c. Ask the woman to describe the symptoms that indicate to her that she has a vaginal infection.
d. Ask the woman to reschedule the appointment for the examination.

 

ANS: C

 

  Feedback
A Although this statement is true, the best response is for the nurse to inquire about the symptoms the woman is experiencing.
B Women should not douche, use vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap test.
C An important element of the history and physical examination is the womans description of any symptoms she may be experiencing.
D Although the woman may need to reschedule a visit for her Pap test, her current symptoms should still be addressed.

 

DIF:   Cognitive Level: Application        REF:  48

OBJ:  Client Needs: Physiologic Integrity                                          TOP:   Nursing Process: Assessment

 

  1. The transition phase during which ovarian function and hormone production decline is called:
a. The climacteric.
b. Menarche.
c. Menopause.
d. Puberty.

 

ANS: A

 

  Feedback
A The climacteric is a transitional phase during which ovarian function and hormone production decline.
B Menarche is the term that denotes the first menstruation.
C Menopause refers only to the last menstrual period.
D Puberty is a broad term that denotes the entire transitional stage between childhood and sexual maturity.

 

DIF:   Cognitive Level: Knowledge        REF:  34

OBJ:  Client Needs: Physiologic Integrity                                          TOP:   Nursing Process: Assessment

 

  1. What opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?
a. Heroin
b. Alcohol
c. PCP
d. Cocaine

 

ANS: A

 

  Feedback
A The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor.
B Alcohol is not an opiate.
C PCP is not an opiate.
D Cocaine is not an opiate.

 

DIF:   Cognitive Level: Comprehension  REF:  40

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

  1. A 20-year-old patient calls the clinic to report that she has found a lump in her breast. The nurses best response is:
a. Dont worry about it. Im sure its nothing.
b. Wear a tight bra, and it should shrink.
c. Many women have benign lumps and bumps in their breasts. However, to make sure that its benign, you should come in for an examination by your physician.
d. Check it again in 1 month and call me back if its still there.

 

ANS: C

 

  Feedback
A Discrediting the patients findings may discourage her from continuing with breast self-examination.
B Wearing a tight bra may irritate the skin and will not cause the lump to shrink.
C Try to ease the patients fear, but provide a time for a thorough evaluation of the lump because it may indicate abnormal changes in the breast.
D Delaying treatment may allow proliferation of abnormal cells.

 

DIF:   Cognitive Level: Analysis             REF:  31

OBJ:  Client Needs: Physiologic Integrity                                          TOP:   Nursing Process: Assessment

 

  1. The body part that both protects the pelvic structures and accommodates the growing fetus during pregnancy is the:
a. Perineum.
b. Bony pelvis.
c. Vaginal vestibule.
d. Fourchette.

 

ANS: B

 

  Feedback
A The perineum covers the pelvic structures; the bony pelvis protects and accommodates the growing fetus.
B The bony pelvis protects and accommodates the growing fetus.
C The vaginal vestibule contains openings to the urethra and vagina; the bony pelvis protects and accommodates the growing fetus.
D The fourchette is formed by the labia minor; the bony pelvis protects and accommodates the growing fetus.

 

DIF:   Cognitive Level: Knowledge        REF:  28

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. A fully matured endometrium that resembles the thickness of heavy, soft velvet describes the _____ phase of the endometrial cycle.
a. Menstrual
b. Proliferative
c. Secretory
d. Ischemic

 

ANS: C

 

  Feedback
A During the menstrual phase, the endometrium is being shed; the endometrium is fully mature again during the secretory phase.
B The proliferative phase is a period of rapid growth, but the endometrium becomes fully mature again during the secretory phase.
C The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual cycle. During this phase, the endometrium becomes fully mature.
D During the ischemic phase, the blood supply is blocked, and necrosis develops. The endometrium is fully mature during the secretory phase.

 

DIF:   Cognitive Level: Comprehension  REF:  34

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called:
a. Bimanual palpation.
b. Rectovaginal palpation.
c. A Papanicolaou (Pap) test.
d. The four As procedure.

 

ANS: C

 

  Feedback
A Bimanual palpation is a physical examination of the vagina; the Pap test is a microscopic examination for cancer.
B Rectovaginal palpation is a physical examination performed through the rectum; the Pap test is a microscopic examination for cancer.
C The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the patients age.
D The four As is an intervention procedure to help a patient stop smoking. The Pap test is a microscopic examination for cancer.

 

DIF:   Cognitive Level: Knowledge        REF:  50, 51

OBJ:  Client Needs: Physiologic Integrity

TOP:  Nursing Process: Implementation

 

  1. While obtaining a detailed history from a woman who has recently emigrated from Somalia, the nurse recognizes that the woman has undergone female genital mutilation (FGM). The nurses best response to this woman is:
a. This is a very abnormal practice and rarely seen in the United States.
b. Do you know who performed this so that it can be reported to the authorities?
c. We will be able to fully restore your circumcision after delivery.
d. The extent of your circumcision will affect the potential for complications.

 

ANS: D

 

  Feedback
A Although this practice is not prevalent in the United States, it is very common in many African and Middle Eastern countries for religious reasons. This response is culturally insensitive.
B The infibulation may have occurred during infancy or childhood. The woman will have little to no recollection of the event. She would have considered this to be a normal milestone during her growth and development.
C The International Council of Nurses has spoken out against this procedure as harmful to a womans health.
D This response is the most appropriate. The patient may experience pain, bleeding, scarring, or infection and may require surgery before childbirth. With the growing number of immigrants from countries where FGM is practiced, nurses will increasingly encounter women who have undergone the procedure.

 

DIF:   Cognitive Level: Analysis             REF:  38

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

MULTIPLE RESPONSE

 

  1. The nurse who is evaluating the woman for potential abuse should be aware that intimate partner violence includes (choose all that apply):
a. Physical abuse.
b. Sexual abuse.
c. Emotional abuse.
d. Psychologic abuse.
e. Economic abuse.

 

ANS: A, B, C, D, E

 

  Feedback
Correct All of these types of abuse can be factors in intimate partner violence.
Incorrect None of the above.

 

DIF:   Cognitive Level: Comprehension  REF:  44

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

Lowdermilk: Maternity Nursing, 8th Edition

 

Chapter 12: Nursing Care of the Family during Labor and Birth

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates that the woman understands the instructions when she states:
a. True labor contractions will subside when I walk around.
b. True labor contractions will cause discomfort over the top of my uterus.
c. True labor contractions will continue and get stronger even if I relax and take a shower.
d. True labor contractions will remain irregular but become stronger.

 

ANS: C

 

  Feedback
A During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.
B During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.
C True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen.
D During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.

 

DIF:   Cognitive Level: Application        REF:  338

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Evaluation

 

  1. When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:
a. Tell the woman to stay home until her membranes rupture.
b. Emphasize that food and fluid intake should stop.
c. Arrange for the woman to come to the hospital for labor evaluation.
d. Ask the woman to describe why she believes she is in labor.

 

ANS: D

  Feedback
A The initial nursing activity should be to gather data about the womans status. The amniotic membranes may or may not spontaneously rupture during labor. The woman may be instructed to stay home until the uterine contractions become strong and regular.
B The initial nursing activity should be to gather data about the womans status. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor such as light foods or clear liquids, depending on the preference of the woman or her primary health care provider.
C Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.
D Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data.

 

DIF:   Cognitive Level: Application        REF:  337

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the womans risk for _____ has increased.
a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension

 

ANS: A

 

  Feedback
A When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis.
B Rupture of membranes (ROM) is not associated with fetal or maternal bleeding.
C Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor.
D ROM has no correlation with supine hypotension.

 

DIF:   Cognitive Level: Comprehension  REF:  352

OBJ:  Client Needs: Physiologic Integrity

TOP:  Nursing Process: Planning, Diagnosis

 

  1. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:
a. Notify the womans primary health care provider immediately.
b. Prepare to administer an oxytocic to stimulate uterine activity.
c. Document the findings because they reflect the expected contraction pattern for the active phase of labor.
d. Prepare the woman for the onset of the second stage of labor.

 

ANS: C

 

  Feedback
A Nothing indicates a need to notify the primary care provider at this time.
B Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor.
C The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the patients medical record. This labor pattern indicates that the woman is in the active phase of the first stage of labor.
D This labor pattern indicates that the woman is in active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

 

DIF:   Cognitive Level: Application        REF:  352

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Implementation

 

  1. When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be:
a. Dilation of the cervix.
b. Descent of the fetus.
c. Rupture of the amniotic membranes.
d. Increase in bloody show.

 

ANS: A

 

  Feedback
A The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor.
B Descent of the fetus, or engagement, may occur before labor.
C Rupture of membranes may occur with or without the presence of labor.
D Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.

 

DIF:   Cognitive Level: Comprehension  REF:  349

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Assessment, Diagnosis

 

  1. The nurse who performs vaginal examinations to assess a womans progress in labor should:
a. Perform an examination at least once every hour during the active phase of labor.
b. Perform the examination with the woman in the supine position.
c. Wear two clean gloves for each examination.
d. Discuss the findings with the woman and her partner.

 

ANS: D

 

  Feedback
A A vaginal examination should be performed only when indicated by the status of the woman and her fetus.
B The woman should be positioned to avoid supine hypotension.
C The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.
D The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider.

 

DIF:   Cognitive Level: Application        REF:  351

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Assessment

 

  1. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurses initial response would be to:
a. Prepare the woman for imminent birth.
b. Notify the womans primary health care provider.
c. Document the characteristics of the fluid.
d. Assess the fetal heart rate and pattern.

 

ANS: D

 

  Feedback
A Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent.
B The nurse may notify the primary care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurses priority is to assess fetal well-being.
C The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.
D The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented.

 

DIF:   Cognitive Level: Application        REF:  352

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

  1. A nulliparous woman who has just begun the second stage of her labor would most likely:
a. Experience a strong urge to bear down.
b. Show perineal bulging.
c. A period of rest and relative calm.
d. Show an increase in bright red bloody show.

 

ANS: C

 

  Feedback
A During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions.
B Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage.
C Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because the worst is over. The woman is quiet and often relaxes with her eyes closed between contractions.
D An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

 

DIF:   Cognitive Level: Comprehension  REF:  360

OBJ:  Client Needs: Psychosocial Integrity                                        TOP:   Nursing Process: Evaluation

 

  1. When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:
a. Encouraging the woman to try various upright positions, including squatting and standing.
b. Telling the woman to start pushing as soon as her cervix is fully dilated.
c. Continuing an epidural anesthetic so pain is reduced and the woman can relax.
d. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

 

ANS: A

 

  Feedback
A Upright positions and squatting both may enhance the progress of fetal descent.
B Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to labor down (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if the woman is able.
C The epidural may mask the sensations and muscle control needed for the woman to push effectively.
D Closed glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

 

DIF:   Cognitive Level: Comprehension  REF:  362

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Implementation

 

  1. Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3 to 4 minutes. The nurse would report this as:
a. First stage, latent phase.
b. First stage, active phase.
c. First stage, transition phase.
d. Second stage, latent phase.

 

ANS: B

 

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