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maternal exam 2 testbank – Questions and Answers
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maternal exam 2 testbank –Questions and Answers
1. The perinatal nurse is assessing a woman at 36 weeks' gestation. Her
fundal height measurement was last recorded at 34 cm. The patient's
abdomen appears to be widest from side to side. The nurse suspects the
possibility of which type of fetal presentation?
A. Breech
B. Cephalic
C. Face
D. Shoulder - -ANS: D
The fetal presentation may be cephalic, breech, or shoulder. The part of the
fetal body first felt by the examining finger during a vaginal examination is
the "presenting part." The shoulder presentation is a transverse lie. This
presentation is rare and occurs in less than 1% of births. When a transverse
lie is present, the maternal abdomen appears large from side to side rather
than up and down. The fetal head is palpated on one maternal side and the
breech is palpated on the other side. Additionally, the woman may
demonstrate a lower-than-expected fundal height measurement for
gestational age.
- 2. The perinatal nurse assessing a laboring woman's contraction intensity
by internal monitoring would expect, during the transition phase, a reading
in which of the following ranges?
A. 10 to 12 mm Hg
B. 20 to 40 mm Hg
C. 50 to 70 mm Hg
D. 70 to 90 mm Hg - -ANS: D
One method to measure the intensity of uterine contractions is with the use
of an internal monitor. If the amniotic membranes have ruptured, an internal
pressure catheter is inserted through the cervix and into the uterus to
measure the internal pressure generated during the contraction. Normally,
the resting pressure in the uterus (between contractions) is 10 to 12 mm Hg.
During the acme, contraction intensity ranges from 25 to 40 mm Hg during
early labor, 50 to 70 mm Hg during active labor, 70 to 90 mm Hg during the
transition phase, and 70 to 100 mm Hg during maternal pushing in the
second stage
- 3. The perinatal nurse knows that when the fetal head is fully extended
and the occiput is near the spine, the delivery team should prepare for the
presenting fetal part to be which of the following?
A. Brow
B. Chin
,C. Face
D. Sacrum - -ANS: C
In the face presentation, the fetal head is fully extended and the occiput is
near the fetal spine. The submentobregmatic diameter presents to the
maternal pelvis; the face is the presenting part
- 4. The perinatal nurse describes different breech positions to the student
nurse. The fetal position with extended legs toward the fetal shoulders is
best described as which of the following?
A. Complete breech
B. Footling breech
C. Frank breech
D. Incomplete breech - -ANS: C
There are three types of breech presentations: frank, complete, and footling.
The frank breech is the most common of all breech presentations. In this
position, the fetal legs are completely extended up toward the fetal
shoulders. The hips are flexed, the knees are extended, and the fetal
buttocks present first in the maternal pelvis. The complete, or full, breech
position is the same as the frank breech position, except the knees are
flexed and the legs crossed, with the fetal buttocks presenting first. In the
footling breech position, one or both of the fetal leg(s) are extended, with
one foot ("single footling") or both feet ("double footling") presenting first
into the maternal pelvis.
- 5. The perinatal nurse is describing the process of fetal engagement to a
group of first-time parents in a prenatal class. The nurse explains that in
primigravidas, the usual time for engagement to occur is which of the
following?
A. 2 weeks before the due date
B. 4 weeks before the due date
C. 6 weeks before the due date
D. During labor - -ANS: A
Engagement is said to have occurred when the widest diameter of the fetal
presenting part has passed through the pelvic inlet. In primigravidas,
engagement usually occurs approximately 2 weeks before the due date. In
multiparas, engagement may occur many weeks before the onset of labor, or
it may take place during labor.
- 6. A nurse is measuring the frequency of a laboring woman's contractions.
How does the nurse accomplish this correctly?
A. Counts the number of contractions measured at the same intensity in 1
full minute
B. Feels the fundus during the acme of the contraction and notes the fundal
firmness
C. Measures the beginning of one contraction to the beginning of the next
contraction
,D. Measures the time from the beginning of one contraction to the end of the
same contraction - -ANS: C
The frequency of contractions is measured from the beginning of one
contraction to the beginning of the next contraction, not by counting
contractions in 1 minute. Feeling the firmness of the fundus during
contractions measures intensity. Measuring the time from the start of one
contraction to the end of the same contraction measures duration.
- 7. A patient's cervix is 8 cm dilated and she is 100% effaced. What action
by the nurse is most important at this time?
A. Allow the support person to be at the bedside.
B. Encourage the woman to bear down.
C. Have the woman avoid pushing at this time.
D. Instruct the woman to rest between contractions. - -ANS: C
Pushing against a partially dilated cervix can lead to cervical edema and
damage and can adversely affect the progress of the woman's labor. It is
most important to protect the patient from injury. Encouraging rest between
contractions and allowing the support person at the bedside are also
important, but safety comes first.
- 8. A nurse reads in a woman's chart that the fetus is in a longitudinal lie.
What can the nurse conclude about this situation?
A. The fetal head is flexed prior to delivery.
B. The fetal head-to-tailbone axis is at a 90° angle to the woman's head-to-
tailbone axis.
C. The fetal head-to-tailbone axis is the same as the woman's head-to-
tailbone axis.
D. Vaginal birth will be very difficult. - -ANS: C
The fetal lie is the relationship of the long axis of the woman to the long axis
of the fetus. If the head-to-tailbone axis of the fetus is the same as the
woman's, the fetus is in a longitudinal lie. This occurs in more than 99% of
pregnancies. Flexion of the fetal head is related to fetal attitude. When the
long axis of the fetus is at a 90° angle to the long axis of the woman, it is
called a transverse lie; this occurs in fewer than 1% of pregnancies.
- 9. At 9:00 a.m., the OB nurse assesses fetal station at 0. The laboring
woman has strong, regular contractions. At 10:30 a.m., the nurse again
assesses fetal station at 0. What action by the nurse is best?
A. Document the findings and continue to assess frequently.
B. Encourage the woman to bear down during contractions.
C. Increase the woman's IV fluid rate and reassess in 30 minutes.
D. Inform the provider and prepare for possible cesarean delivery - -ANS: D
As labor advances and the presenting fetal part descends, the station should
progress to a numerically higher positive station (numerically higher positive
number). If the station does not change in the presence of strong, regular
contractions, this may indicate a problem with the relationship between the
, maternal pelvis and the fetus (cephalopelvic disproportion). The nurse should
inform the provider and prepare for a possible cesarean delivery.
Documentation should occur in all situations, but more action is needed.
Increasing the IV fluid rate is not warranted. The woman should be
encouraged to bear down only after the cervix is totally dilated.
- 10. A nurse assesses the fetal position in a laboring woman. The fetal
position is documented as LSP. What action by the nurse is best?
A. Continue to support the woman's labor efforts.
B. Document the findings in the woman's chart.
C. Inform the provider; prepare for possible cesarean delivery.
D. Turn the woman on her left side; reassess in 30 minutes. - -ANS: C
LSP indicates left, sacrum, posterior. This malpresentation may signal the
need for a cesarean delivery. The nurse should not just support the woman's
labor efforts, nor should the nurse document without taking other action.
Turning the woman on her left side is not warranted.
- 11. A woman who is 40 weeks pregnant calls the clinic to report that she
noted a small amount of blood-tinged mucus on her toilet tissue this
morning. What response by the nurse is most appropriate?
A. "Come to the clinic today for an examination."
B. "Labor will probably start within 48 hours."
C. "Lie on your left side and count fetal kicks."
D. "Stay on bedrest until your labor begins." - -ANS: B
During pregnancy, the cervix is plugged with mucus. When effacement
begins, small capillaries can rupture, leading to an expulsion of the blood-
tinged mucus plug, called bloody show. Its presence often indicates that
labor will begin in 24 to 48 hours. No action is needed at this time.
- 12. A woman arrives at the birthing unit complaining of frequent strong
contractions that begin in her back and cannot be relieved by walking or
changing positions. What action by the nurse is most appropriate?
A. Assess the woman for rupture of membranes.
B. Immediately notify the woman's primary care provider.
C. Reassure the woman and send her home.
D. Review the signs of true labor with the woman. - -ANS: A
Distinguishing true labor from false labor can be difficult. True labor
contractions occur with regularity, increased in frequency and duration, and
usually begin in the woman's lower back and radiate to the abdomen. Based
on the woman's description, the contractions likely are indicative of true
labor, so she should be assessed further, including assessment for rupture of
membranes. There is no urgent need to notify her primary care provider until
further assessment is completed. She should not be sent home, nor does she
need more education on the signs of true labor.
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