NURS 2863 maternity exam 2A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe:
A) weight gain of 1 to 3 lbs.
B) quickening.
C) fatigue and lethargy. D) bloody show.
The nurse should tell a primigravi...
nurs 2863 maternity exam 2 a primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer the nurse should describe a weight gain of 1 to 3
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NU
Maternity
Exam 2
NURS 2863 maternity exam 2
A primigravida asks the nurse about signs she can look for that would
indicate that the onset of labor is getting closer. The nurse should describe:
A) weight gain of 1 to 3 lbs.
B) quickening.
C) fatigue and
lethargy. D) bloody
show.
The nurse should tell a primigravida that the definitive sign indicating that
labor has begun would be:
A) progressive uterine contractions with cervical change.
B) lightening.
C) rupture of membranes.
D) passage of the mucous plug (operculum).
On completion of a vaginal examination on a laboring woman, the nurse
records: 50%, 6 cm, -1. What is a correct interpretation of the data?
A) The fetal presenting part is 1 cm above the ischial spines.
B) Effacement is 4 cm from completion.
C) Dilation is 50% completed.
D) The fetus has achieved passage through the ischial spines.
In order to accurately assess the health of the mother accurately during
labor, the nurse should be aware that:
A) The woman's blood pressure increases during contractions and falls back
to prelabor normal between contractions.
B) Use of the Valsalva maneuver is encouraged during the second stage
of labor to relieve fetal hypoxia.
C) Having the woman point her toes reduces leg cramps.
D) The endogenous endorphins released during labor raise the woman's
pain threshold and produce sedation.
The nurse knows that the second stage of labor, the descent phase, has
begun when:
A) the amniotic membranes rupture.
B) The cervix cannot be felt during a vaginal examination.
C) The woman experiences a strong urge to bear down.
D) The presenting part is below the ischial spines.
Nurses can help their clients by keeping them informed about the distinctive
stages of labor. What description of the phases of the first stage of labor is
accurate?
A) Latent: mild, regular contractions; no dilation; bloody show; duration of 2
,NU
Maternity
Exam 2
to 4 hours
B) Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3
to 6 hours
C) Lull: no contractions; dilation stable; duration of 20 to 60 minutes
D) Transition: very strong but irregular contractions; 8 to 10 cm dilation;
duration of 1 to 2 hours
Which position would the nurse suggest for second-stage labor if the pelvic
outlet needs to be increased?
A) Semirecumbent
B) Sitting
C) Squatting
D) Side-lying
Concerning the third stage of labor, nurses should be aware that:
A) the placenta eventually detaches itself from a flaccid uterus
B) The duration of the third stage may be as short as 3 to 5 minutes
C) it is important that the dark, roughened maternal surface of the placenta
appear before the shiny fetal surface
D) the major risk for women during the third stage is a rapid heart rate
The charge nurse on the maternity unit is orienting a new nurse to the unit
and explains that the 5 Ps of labor and birth are: (Select all that apply.)
A) passenger.
B) placenta.
C)
passageway.
D) psychologic
response. E) powers.
F) position.
Nurses can advise their patients that which of these signs precede labor?
(Select all that apply.)
A. A return of urinary frequency as a result of increased bladder pressure
B. Persistent low backache from relaxed pelvic joints
C. Stronger and more frequent uterine (Braxton Hicks) contractions
D. A decline in energy, as the body stores up for labor
E. Uterus sinks downward and forward in first-time pregnancies.
The maternity nurse should notify the health care provider about which
assessment findings during labor? (Select all that apply.)
A. Positive urine drug screen
B. Blood glucose level of 78 mg/dL
C. Increased systolic blood pressure during first stage
,NU
Maternity
Exam 2
D. Elevated white blood cell count
E. Oral temperature of 99.8° F
F. Respiratory rate of 10 breaths/min
A laboring woman becomes anxious during the transition phase of the first
stage of labor and develops a rapid and deep respiratory pattern. She
complains of feeling dizzy and light-headed. The nurse's immediate response
would be to:
A. encourage the woman to breathe more slowly.
B. help the woman breathe into a paper bag.
C. turn the woman on her side.
D. administer a sedative.
A woman is in the second stage of labor and has a spinal block in place for
pain management. The nurse obtains the woman's blood pressure and
notes that it is 20% lower than the baseline level. Which action should the
nurse take?
A. Encourage her to empty her bladder.
B. Decrease her intravenous (IV) rate to a keep vein-open rate.
C. Turn the woman to the left lateral position or place a pillow under her hip.
D. No action is necessary since a decrease in the woman's blood pressure
is expected.
A woman in latent labor who is positive for opiates on the urine drug screen
is complaining of severe pain. Maternal vital signs are stable, and the fetal
heart monitor displays a reassuring pattern. The nurse's MOST appropriate
analgesic for pain control is:
A. fentanyl (Sublimaze).
B.promethazine (Phenergan).
C. butorphanol tartrate (Stadol).
D. nalbuphine (Nubain).
A woman is experiencing back labor and complains of constant, intense pain
in her lower back. An effective relief measure is to use:
A. counterpressure against the sacrum.
B. pant-blow (breaths and puffs) breathing techniques.
C. effleurage.
D. biofeedback.
, NU
Maternity
Exam 2
Nurses should be aware of the difference experience can make in labor pain,
such as:
A. sensory pain for nulliparous women often is greater than for multiparous
women during early labor.
B. affective pain for nulliparous women usually is less than for multiparous
women throughout the first stage of labor.
C. women with a history of substance abuse experience more pain during
labor.
D. multiparous women have more fatigue from labor and therefore
experience more pain.
With regard to what might be called the tactile approaches to comfort
management, nurses should be aware that:
A. either hot or cold applications may provide relief, but they should never be
used together in the same treatment.
B. acupuncture can be performed by a skilled nurse with just a little training.
C. hand and foot massage may be especially relaxing in advanced labor
when a woman's tolerance for touch is limited.
D. therapeutic touch (TT) uses handheld electronic stimulators that produce
sympathetic vibrations.
With regard to systemic analgesics administered during labor, nurses should
be aware that:
A. systemic analgesics cross the maternal blood-brain barrier as easily as
they do the fetal blood-brain barrier.
B. effects on the fetus and newborn can include decreased alertness and
delayed sucking.
C. IM administration is preferred over IV administration.
D. IV patient-controlled analgesia (PCA) results in increased use of an
analgesic.
After change of shift report, the nurse assumes care of a multiparous patient
in labor. The woman is complaining of pain that radiates to her abdominal
wall, lower back, buttocks, and down her thighs. Before implementing a plan
of care, the nurse should understand that this type of pain is:
A. visceral.
B. referred.
C. somatic.
D. afterpain.
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