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WorksheetsNURS 4407 EXAM 1
Total questions: 45
Worksheet time: 25mins
A 39 year old female is currently 18 weeks pregnant. She has two sets of twin daughters that were born at 38 and 39 weeks gestation and an 11 year-old son who was born at 32 weeks gestation. She has no history of miscarriage or abortion. What is her GTPAL?
G4, T2, P2, A1, L5
G4, T1, P1, A0, L4
G4, T1, P2, A1, L4
G4, T2, P1, A0, L5
A 38 week gestation mother comes into the hospital for delivery. After reviewing her admission labs, you notice that her WBCs are slightly elevated. When checking her vitals, her HR & BP are slightly elevated as well as her temperature. What should the nurse do?
Call the provider to notify them of the abnormal labs
Suspect maternal infection and do further testing
Get consents signed for a STAT CS
Document the findings in the patients chart
A 39wks gestation mother is laboring on your floor. When you last went in to check on her, she was 4cm dilated, smiling, and conversing with her family. This time when you checked on her, she was stern, stressed, and verbalizing major anxiety about delivering this baby. What should the nurse do?
Request a psych consult
Say "It's okay mom, this labor will be over quick and everything will be better"
Check her cervix to see if she has entered the active labor stage and provide education
Tell the family to leave the room to allow for privacy
Your laboring patient is having trouble progressing in labor and her contractions have been weak and far apart. Which intervention would help to progress labor naturally?
Have mom lay in bed on her left lateral side and practice deep breathing
Give mom a big glass of juice to stimulate baby's activity
Help mom position herself on a birthing ball
Administer pain meds so she stops thinking about the pain
Your postpartum mom calls you into her room in tears. She tells you "I just went through all that hard work to delivery my baby that i've been waiting 9 months to meet, but im feeling a little sad. Does that make me a bad mom?" What is the most therapeutic response?
"During the postpartum period, your endorphins drop and can cause some postpartum blues. It is normal to feel a little down."
"Would you like for me to take your baby so you can rest some? I'm sure you are just tired."
"Every mom is different. It's okay if you don't feel bonded with you baby right now."
"This is a sign of postpartum depression. I am going to notify your provider and we will conduct a screening to ensure you are not a safety risk to yourself or others."
In the hand off report on the L&D floor, the RN states that your baby is at 0 station. How would you interpret this finding?
Babies head floats slightly when tapped and is level with the ischial crest.
Mom is crowning and ready to deliver.
Babies head does not move when tapped and level with the ischial spine
Babies head does not move when tapped and level with the iliac crest
True or False: Stage 2 of labor begins with the delivery of the baby and ends with the delivery of the placenta.
True
False
What is the definition of true labor
complete rupture of membranes
progressive cervical change
Complete dilation and effacement
intense and even contractions
The mother has delivered the placenta. You note that the shiny surface of the placenta was delivered first. How would you document this and is it considered baby side or maternal side?
Duncan mechanism, maternal
Schultze mechanism, maternal
Schultze mechanism, baby
Duncan mechanism, baby
Your 39 wks gestation mother is requesting her cervix be checked. When assessing baby's station, you note that baby is floating about 2 centimeters above the ischial spine. How would you document this finding?
-2 station
+2 station
engaged
station 0
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
The contractions are regular
The membranes have ruptured
The cervix is dilated completely
The client begins to expel clear vaginal fluid
what is the most ideal fetal presentation
OA
OP
Cephalic
Asynclitism
Your laboring client asks when is the best time for her to push. How should you respond?
"in between contractions when the pain is less severe"
"whenever you feel comfortable enough to push"
"push at the same time as your contractions"
"don't push unless I tell you you can"
A laboring mother with a history of sexual abuse is assigned to you. When you go in to check her cervix, what is the most therapeutic statement?
say "I know this may be uncomfortable, but I need to check your cervix. I will be quick"
Insert your fingers and say "I am just checking your cervix. you may feel some pressure"
before beginning say "I would like to check your cervix. I will place 2 fingers in your vagina to see how dilated you are. Is that okay with you?"
say "I am not your abuser so there's no need to be scared of me"
Which of the following are labor warning signs?
constipation
loss of mucus plug
sudden weight gain
bloody show
lightening
A 38wks gestation mother calls your unit and says that she had a gush of fluids this morning in the shower. She asks if she should come in. What is the best response?
"Rupture of membranes does not mean active labor, so you don't have to come in until your contractions are strong and close together."
"yes, we will prepare a room for you."
"I'm not sure. Let me call your provider."
"you are in labor, so yes"
You perform a Ferning test on a mom with suspected ROM. Which result would indicate amniotic fluid?
The paper turns blue
the lab sends back a positive result
fluids expel when mom coughs
there are "snowflakes" under the microscope
Which findings indicate mom is in the 3rd stage of labor
Baby's head is delivered
mom is doing skin to skin
the umbilical cord is elongating
there is a gush of clear fluids
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
DTR of 2+
absent clonus
Decreased BP
RR of 9
A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if:
BP is reduced to prepregnant baseline
seizures do not occur
DTR become hypotonic
Diuresis reduces fluid retention
The most prevalent clinical manifestation of placental abruption (as opposed to placenta previa) is:
intense bleeding
intense abdominal pain
cramping
Uterine activity
A pregnant woman presents to the emergency department complaining of persistent nausea and vomiting. She is diagnosed with hyperemesis gravidarum. The nurse should include which information when teaching about diet for hyperemesis? (Select all that apply.)
Eat 3 larger meals a day
Avoid ginger goods
eat what sounds good to you even if its not well-balanced
don't eat cold foods and hot foods in the same sitting
eat smaller meals throughout the day
What action does the nurse take to relieve choking in a pregnant patient who is in the third trimester?
administer anesthesia
administer chest thrusts
place towel under hips
position onto one side
A woman comes in with a positive pregnancy test. Upon transvaginal ultrasound, you notice no fetus in the uterus. Which intervention would you anticipate?
Prepare patient for D&C
Consult psych because the client is faking a pregnancy
suspect ectopic pregnancy and prepare to administer methotrexate
Tell mom she had an abortion and offer emotional support
What does the nurse include in the plan of care of a pregnant patient with mild preeclampsia? Select all that apply.
ensure prolonged bed rest with no bathroom privileges
restrict sodium
restrict activity at home
schedule frequent office visits for NST's
administer Mag Sulfate
Which of the following puts the patient at risk for an spontaneous abortion?
Gestational age >35
tobacco use
infection
caffiene
A mom who just had a molar pregnancy came into the office for her first follow up. Which statement by the client indicates need for further teaching?
"I need to plan on several follow up appointments to monitor my hCG"
"There is a chance that my hCG levels rise again if not all cells were removed"
"Once my hCG levels stabilize, I can try for another baby"
"I need to avoid pregnancy for at least 1 year"
True or false: Once a pre-eclampic mom delivers her baby, the nurse can discontinue the Mag sulfate because the cure to preeclampsia is delivery.
True
False
Which of the following are considered severe features?
Pancytopenia
Impaired liver funtion
vision changes
ESRD
HTN
What chemical substance(s) produced in the body acts as a natural pain reliever?
endorphins
morphine
codeine
atropine
A nurse instructs a womans labor coach to comfort her by firmly pressing on her lower back. What is this technique?
Counter pressure
distraction
conscious relaxation
effleurage
A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor?
it can cause medications given at later stages to be ineffective
it will have no complications for the mother or infant
it may result in respiratory depression to the newborn
it will speed up labor and increase pain
A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent?
N/V
Vomiting and aspiration
abdominal cramping
intestinal obstruction
A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia?
reduce fetal HR
Long, intense contractions
sudden leg cramps
bladder distension
An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, Please give me something for the pain. I cant take the pain! What is the priority nursing diagnosis?
pain related to uterine contractions
knowledge deficit related to the birth experience
ineffective coping related to inadequate preparation for labor
risk for injury related to lack or prenatal care
The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause?
increased use of oxygen
cervical laceration
uterine rupture
compression of cord
A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurses best response to explain the frequent blood pressure assessments?
they ensure that unsafe levels of HTN do not occur
they help assess for the need for further pain relief
they monitor the progress of labor
they ensure adequate placental perfusion
which statement by the client indicates understanding of the drug Butorphanol
"butorphanol will relieve all of my labor pain"
"this medication crosses the placenta and can affect my baby"
"this will make me feel crazy and drunk"
" i can receive this med up until i am completely dilated"
On the fetal heart monitor you see early decelerations. What is the cause of this finding
the babys head is pressing against the pelvis or soft tissue
it is due to uteroplacental insufficiency
it is caused by cord compression
it is caused by a prolapsed uterus
Which of the following statements describe a variable deceleration?
On the fetal tracing, the heart rate will mirror the mother’s contraction and represent uteroplacental insufficiency.
On the fetal tracing, the heart rate will increase after the mother’s contraction and return to baseline after the contraction ends
On the fetal tracing, the heart rate will decline sharply present when the cord is being compressed.
Variable decelerations are uniform
You notice prolonged decels on your moms fetal strip. what action should the nurse anticipate?
Have mom sign consent form for STAT CS
apply surgical glove and apply fundal pressure
don sterile gloves and lift presenting part off of umbilical cord
prepare for amnioinfusion
Which declaration can be treated with an amnioinfusion
early decels
late decels
variable decels
sinusoidal
what steps are apart of the stress protocol
Place mom lateral sides
lay mom supine
increase pit
10L O2 via face mask
bolus fluids
A fetal heart stip is showing fetal bradycardia. How should the nurse interpret this finding?
The baby's head is being compressed
baby is sleeping and needs to be stimulated
baby has decreased perfusion dt either cord compression, drugs, or maternal hypotension.
baby is having minimal fluctuations in normal FHR due to either hypoxic or nonhypoxic causes
Mom and baby are experiencing tachycardia rt mild fever. which intervention should the nurse perform.
administer ibuprophen
administer tylenol
Perform stress protocol
bolus fluids
