Maternity Questions

Chapter 16

Maternity Questions

83. The nurse is performing a postpartum fundal assessment and notes that the client’s uterus feels soft and spongy. Which nursing action(s) are most appropriate initially? Select all that apply.

1 Massage the fundus gently.

2 Notify the health care provider.

3 Encourage the mother to ambulate.

4 Observe for increased vaginal bleeding or clots.

5 Document fundal position, consistency, and height.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

ANSWER: 1, 4, 5

Rationale:

If the uterus feels soft and spongy (boggy), it should be massaged gently, observing for increased vaginal bleeding or clots. Option 3 is inappropriate at this time and could be harmful. The nurse should document fundal position, consistency, and height and the need to perform fundal massage, along with the client’s response to the intervention. The health care provider is notified if uterine massage is not helpful.

Test-Taking Strategy:

Note the strategic words most appropriate initially. Note the relationship of the data in the question (soft and spongy) and the data in the correct options. Also recall that actions need to be taken if the uterus is soft and boggy. Review: nursing interventions related to fundal assessment.

Tip for the Beginning Nursing Student:

The postpartum period is the time following delivery of a newborn. During this time, the nurse needs to check the new mother’s fundus for firmness. If the fundus is soft and boggy (and not firm as it should be), the nurse should gently massage the fundus. You will learn about the postpartum period and associated nursing interventions in your maternity nursing course when you study postpartum assessments.

References

Leifer (2011), pp. 238-239; Lowdermilk et al (2012), pp. 493-494, 826.

84. A client arrives at the prenatal clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period (LMP) was August 19, 2014. Using Nägele’s rule, the nurse determines the estimated date of delivery as which date?

1. May 12, 2015

2. May 26, 2015

3. June 12, 2015

4. June 26, 2015

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/ Assessment/Data Collection

Content Area:

ANSWER: 2

Rationale:

Accurate use of Nägele’s rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the LMP, add 7 days, and then add 1 year to that date if it is appropriate to change it to the next year. First day of the LMP is August 19, 2014; subtract 3 months: May 19, 2014; add 7 days: May 26, 2014; add 1 year: May 26, 2015.

Test-Taking Strategy:

Focus on the subject, accurate use of this rule. Use Nägele’s rule to answer this question, but use caution when following the steps to determine the estimated date of delivery. Read all options carefully, noting the dates and years in each before selecting an option. Review: Nägele’s rule.

Tip for the Beginning Nursing Student:

Nägele’s rule is a method of determining the date of delivery for a client who is pregnant. Determining the date of delivery requires knowing the date of the LMP and then using the rule to determine the delivery date. This is a simple way to determine the date, and memorizing the rule will assist you in determining a client’s delivery date. You will learn about Nägele’s rule and how to use the rule to determine the delivery date in your maternity nursing course when you study prenatal assessment procedures.

References

Leifer (2011), p. 48; Lowdermilk et al (2012), p. 330.

85. The nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia and is assessing the client every 30 minutes. Which finding indicates a need to immediately contact the health care provider?

1. Urinary output of 20 mL

2. Deep tendon reflexes of 2 +

3. Respirations of 10 breaths/minute

4. Fetal heart rate (FHR) of 116 beats/minute

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/ Assessment/Data Collection

Content Area:

ANSWER: 3

Rationale:

Magnesium sulfate depresses the respiratory rate. If the rate is less than 12 breaths/minute, continuation of the medication needs to be reassessed. The acceptable criterion for urine output is at least 30 mL/hour. The amount of urine output identified in option 1 is adequate (20 mL of urine in 30 minutes). Deep tendon reflexes of 2 + are normal. The FHR is within normal limits for a resting fetus.

Test-Taking Strategy:

Note the strategic word immediately. Select the option that indicates an abnormal finding that requires further intervention. Recalling the normal respiratory rate will direct you to option 3. Review: the findings in preeclampsia.

Tip for the Beginning Nursing Student:

Preeclampsia is an abnormal condition of pregnancy characterized by the onset of acute hypertension after week 24 of pregnancy. The classic signs include hypertension, proteinuria (protein in the urine), and edema (swelling). One concern is that preeclampsia can progress to eclampsia (seizures). Preeclampsia is treated with magnesium sulfate to prevent its progression to eclampsia. The nurse needs to monitor closely the client receiving this medication because of its many adverse effects and the risk of toxicity. One primary concern is that magnesium sulfate depresses respirations; therefore, the nurse monitors the client’s respiratory status closely. You will learn about this medication and important nursing interventions when it is administered in a pharmacology course or in your maternity nursing course when you study high-risk conditions in pregnancy.

References

Leifer (2011), p. 94; Lowdermilk et al (2012), p. 665.

86. The nurse receives report at the beginning of the shift about a client with an intrauterine fetal demise. On assessment of the client, the nurse expects to note which finding?

1. Intractable vomiting and dehydration

2. Elevated blood pressure, proteinuria, and edema

3. Uterine size greater than expected for gestational age

4. Regression of pregnancy symptoms and absence of fetal heart tones

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/ Assessment/Data Collection

Content Area:

ANSWER: 4

Rationale:

Symptoms of a fetal demise include decreased fetal movement, unchanged or decreased fundal height, and absent fetal heart tones. In addition, many symptoms of the pregnancy may diminish, such as breast size and tenderness. Option 1 is associated with hyperemesis gravidarum. Option 2 is associated with preeclampsia. Option 3 is unrelated to intrauterine fetal demise.

Test-Taking Strategy:

Focus on the subject, intrauterine fetal demise. Note the relationship between the subject and option 4. Recalling that fetal demise means fetal death will direct you to the correct option. Review the signs associated with intrauterine fetal demise.

Tip for the Beginning Nursing Student:

Fetal demise refers to the intrauterine death of a fetus. If this occurs, fetal movement and heart tones would be absent. Hyperemesis gravidarum is an abnormal condition of pregnancy characterized by protracted vomiting, weight loss, and fluid and electrolyte imbalance. Preeclampsia is an abnormal condition of pregnancy characterized by the onset of acute hypertension after week 24 of pregnancy. The classic signs include hypertension, proteinuria (protein in the urine), and edema (swelling). You will learn about these complications of pregnancy in your maternity nursing course.

References

Murray, McKinney (2010), pp. 724-725, 727.

87. Immediately following the delivery of a newborn infant, the nurse prepares to assist in the delivery of the placenta. What is the appropriate action to deliver the placenta?

1. Pull on the umbilical cord.

2. Instruct the mother to push during a uterine contraction.

3. Place traction on the umbilical cord and pull on the placenta as it enters the vaginal canal.

4. Separate the placenta from the uterine wall using the forceps, and then allow the placenta to deliver spontaneously.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

ANSWER: 2

Rationale:

After the placenta separates, the mother is instructed to push during a uterine contraction. Pulling on the umbilical cord or placing traction on the umbilical cord may cause it to break, making the placenta harder to deliver. The placenta is not separated from the uterine wall using forceps. This may result in bleeding.

Test-Taking Strategy:

Focus on the subject, actions to assist in the delivery of a placenta. Eliminate option 1 because of the word pull and option 3 because of the word traction. From the remaining options, eliminate option 4 by recalling that the placenta is attached to the uterine wall and unnatural separation will result in bleeding. Review: the procedure for placental delivery.

Tip for the Beginning Nursing Student:

The placenta is a fetal structure that provides nourishment to and removes wastes from the developing fetus. After the delivery of the baby, the placenta separates from the uterine wall and is delivered. You will learn about the purpose of the placenta and its delivery in your maternity nursing course.

References

Leifer (2011), pp. 146-147; Lowdermilk et al (2012), p. 471.

88. A client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse should identify which priority problem for this client?

1. Inability to cope

2. Lack of knowledge

3. Ineffective grieving

4. Lowered self-esteem

Level of Cognitive Ability:

Client Needs:

Health Promotion and Maintenance

Integrated Process:

Nursing Process/Planning

Content Area:

ANSWER: 2

Rationale:

Lack of knowledge indicates a lack of information or psychomotor skill concerning a skill, condition, or treatment. This problem best describes the situation presented in the question. Inability to cope implies that the person is unable to manage stressors adequately. Ineffective grieving implies prolonged unresolved grief leading to detrimental activities. Lowered self-esteem represents temporary negative feelings about self in response to an event.

Test-Taking Strategy:

Note the strategic word priority. When a question asks to identify a priority client problem, focus on the information in the question. Option 2 will focus on the mother’s concern about knowing how to care for her first-born child. Review: care of the first-time mother.

Tip for the Beginning Nursing Student:

Teaching is an important nursing responsibility. It is common for a new mother to be concerned about how to care for her newborn. The nurse needs to alleviate fears and concerns by providing the mother with opportunities to care for the newborn after delivery while hospitalized. You will learn about therapeutic measures to alleviate these concerns and fears and the important points to teach the mother about caring for her newborn in your maternity nursing course.

References

Murray, McKinney (2010), p. 516; Christensen, Kockrow (2011), p. 860.

89. The nurse is monitoring the status of a client in labor who is experiencing hypotonic uterine dysfunction. The nurse interprets that which finding would least likely be consistent with this type of dysfunctional labor?

1. Contractions weaken during the active stage of labor.

2. Contractions become inefficient or stop during the active stage of labor.

3. The client initially makes normal progress into the active stage of labor, and then contractions weaken.

4. The client is having painful and frequent contractions that are ineffective in causing cervical dilation or effacement to progress.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/ Assessment/Data Collection

Content Area:

ANSWER: 4

Rationale:

In hypotonic uterine dysfunction the client initially makes normal progress into the active stage of labor and then contractions weaken, become inefficient, or stop. Option 4 is characteristic of hypertonic uterine dysfunction.

Test-Taking Strategy:

Note the strategic words least likely. These words indicate a negative event query and that you need to identify the option that is not characteristic of hypotonic uterine dysfunction. Noting that options 1, 2, and 3 are comparable or alike and noting the word hypotonic in the question will direct you to the correct option. Review: manifestations of hypotonic uterine dysfunction.

Tip for the Beginning Nursing Student:

A contraction is a rhythmic tightening of the musculature of the upper uterus that begins as mild tightening and progresses to strong tightening late in labor. Contractions decrease the size of the uterus and push the fetus through the birth canal. Normal labor contractions are coordinated, involuntary, and intermittent. You will learn about contractions and the labor process in your maternity nursing course.

References

Leifer (2011), pp. 185-186; Lowdermilk et al (2012), p. 792.

90. A client has just experienced a precipitate labor. The nurse notes that the mother is lying quietly in bed and is avoiding physical contact with her newborn infant. What is the most appropriate nursing action?

1. Request a psychiatric consult.

2. Provide support to the mother.

3. Contact the health care provider.

4. Encourage the mother to breast-feed the infant.

Level of Cognitive Ability:

Client Needs:

Psychosocial Integrity

Integrated Process:

Content Area:

ANSWER: 2

Rationale:

Precipitate labor is defined as labor that lasts less than 3 hours from the onset of contractions to the time of birth. After a precipitate labor, the mother may need help to process what has happened and time to assimilate it all. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or simply following cultural norms. Providing support to the mother is the most appropriate and therapeutic action by the nurse. Options 1 and 3 do not enhance the therapeutic relationship. Option 4 is an appropriate nursing intervention, but the question does not indicate whether the mother is going to be breast-feeding.

Test-Taking Strategy:

Note the strategic words most appropriate. Eliminate options 1 and 3 first because they are comparable or alike. From the remaining options, note that no data indicate that the mother is going to breast-feed. This will direct you to the correct option. Review: care of the client following precipitate labor.

Tip for the Beginning Nursing Student:

The total duration of normal labor differs for women who have never given birth and for those who have previously given birth by the vaginal route. Normal labor consists of four stages. In the first stage, which normally lasts 6 to 10 hours (but can be longer), effacement and dilation occur. The second stage involves expulsion of the fetus and normally lasts 20 to 60 minutes. Stage three involves separation of the placenta and usually takes 5 to 30 minutes. Stage four, which lasts 1 to 4 hours after delivery, is the time for physical recovery and newborn bonding. You will learn about the normal labor process and the stages of labor in your maternity nursing course.

References

Christensen, Kockrow: Foundations (2011), pp. 834-835; Lowdermilk et al (2012), p. 794.

91. A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should use which approach as the first step to support the client psychologically?

1. Avoid talking about the dead fetus.

2. Assess how the client perceived the event.

3. Ask the client and husband about plans for future pregnancies.

4. Suggest that family members see and hold the dead infant if they wish.

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Tags: Saunders 2014-2015 Strategies for Test Success Passing Nursing S

Jul 24, 2016 | Posted by admin in NURSING | Comments Off

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