12.The charge nurse on the labor unit is in charge of admissions.
There are several admission requests for oxytocin induction of
labor. Which of the following candidates would be appropriate
for urgent induction on a busy labor unit?
a. Pt with a blood pressure of 156/90 and IUGR
b. Pt with active herpes lesion
c. Pt with a breech presentation
d. Pt with a fetus demonstrating variable and late decelerations
—Pitocin would stress the baby out more
e. Pt with a fetus demonstrating marked variability
f. Pt with positive group B strep status at 36 weeks Correct
Answers A--preeclampsia/ severe hypertension (we need to get
this baby out)
23. The nurse will prepare for which of the following
interventions to effectively manage this
patient's care?
a. Bed rest and hydration at home
b. Hospitalization, tocolytic therapy, and IM corticosteroids
c. An emergency cesarean section
d. Continuous external fetal monitoring and IV therapy Correct
Answers B--tocolytics to help delay delivery, and
corticosteroids for lung maturity
26. A primigravida has just vaginally given birth to a baby girl
after pushing for 3 hours.
The initial newborn assessment at one minute after birth is:
color pink with blue extremities,
, respirations 44 breaths/min with moist rales, heart rate 98 bpm,
flexion of all
extremities, and coughs and cries with stimulation. The nurse
interprets this baby's one
minute apgar as:
a. 5
b. 7
c. 8
d. 9 Correct Answers 8--normal respiratory rate of newborns is
between 30-60
pink with blue extremities=1
respiration 44 with moist rales=2
HR 98=1
Flexion of extremities= 2
Cough and cries= 2
Total= 8
3 hours later the Bishop score is 8 and the health care provider
orders oxytocin. After one hour of IV Oxytocin, Tina's uterine
contraction pattern becomes regular occurring every 3-5
minutes. Tina's cervix has changed from 2 cm to 4 cm and 100%
effaced. The physician suggests artificial rupture of membranes
(AROM) to augment the labor. Tina agrees.
9. The physician performs an AROM with return of moderate
green colored meconium-
stained amniotic fluid. Tina expresses great concern with the
color of the amniotic fluid and
asks, "What does this mean?". The best explanation by the
nurse would be:
,a. "The amniotic fluid contains meconium which the baby
passed in utero."
b. "The baby has released its first stool in utero because of lack
of glucose."
c. "Meconium is the baby's first stool and is not a concern until
delivery."
d. "This means the baby is stressed from labor and the physician
will need to do a cesarean Correct Answers A
3. In reviewing Marsha's prenatal history, the nurse notes which
of the following as a
risk for vaginal bleeding?
a. Macrosomia
b. Gestational hypertension
c. Poor nutritional status
d. Gestational diabetes Correct Answers B
5. The perinatal nurse notes a rapid decrease in the fetal heart
rate that does not recover immediately following an amniotomy.
What action should the nurse perform first?
a. administer oxygen at 100%
b. assess the maternal temperature
c. Perform a vaginal exam
d. Recheck the fetal heart rate in 5 minutes
Please state your rationale for your selected response. Correct
Answers C--make sure its not the cord being compressed,
because an amniotomy can cause the head to lower, and could
compress cord
8. The nurses anticipates the following medication to be used for
this patient.
, a. betamethasone
b. hydromorphone
c. dinoprostone
d. oxytocin Correct Answers C--help with lung maturity?
After rupture of membranes, the nurse assesses the fetal heart
pattern on the external fetal monitor (EFM). Following is the
description: uterine contractions every 3-5 minutes, lasting 40-
50 seconds and palpated as moderate intensity. The FHR
baseline is 120 with three decelerations to 100 bpm beginning
after the acme of each contraction, lasting for 10-15 seconds and
then returning to baseline.
10. In the above situation, based upon the FHR pattern, the
nurse's FIRST action
should be to:
a. Call the physician
b. Turn the patient on her back
c. Turn off the IV Pitocin
d. Increase the IV fluid rate Correct Answers C--due to
indication of fetal distress, adverse effect of Pitocin (oxytocin)
At what blood glucose level should our patients levels be
maintained at? Correct Answers 80-120 mg/dL
Case #1- Marsha
A new registered nurse arrives on the labor unit and receives
change of shift report. There are four pregnant women on the
unit.
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