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MULTIPLE CHOICE
1. In planning for home care of a woman with preterm labor, which concern
should the nurse need to address?
a. Nursing assessments are different from
those performed in the hospital setting.
b. Restricted activity and medications are
necessary to prevent a recurrence of
preterm labor.
c. Prolonged bed rest may cause negative
physiologic effects.
d. Home health care providers are necessary.
ANS: C
Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle
wasting, weakness, bone demineralization, decreased cardiac output, risk for
thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged
postpartum recovery. Nursing assessments differ somewhat from those performed in the
acute care setting, but this concern does not need to be addressed. Restricted activity and
medications may prevent preterm labor but not in all women. In addition, the plan of care
is individualized to meet the needs of each client. Many women receive home health
nurse visits, but care is individualized for each woman.
6. A woman is having her first child. She has been in labor for 15 hours. A
vaginal examination performed 2 hours earlier revealed the cervix to be dilated to 5 cm
and 100% effaced, and the presenting part of the fetus was at station 0; however, another
vaginal examination performed 5 minutes ago indicated no changes. What abnormal
labor pattern is associated with this description?
a. Prolonged latent phase
b. Protracted active phase
c. Secondary arrest
d. Protracted descent
ANS: C
With a secondary arrest of the active phase, the progress of labor has stopped. This client
has not had any anticipated cervical change, indicating an arrest of labor. In the
nulliparous woman, a prolonged latent phase typically lasts longer than 20 hours. A
protracted active phase, the first or second stage of labor, is prolonged (slow dilation).
With a protracted descent, the fetus fails to descend at an anticipated rate during the
deceleration phase and second stage of labor.
9. The obstetric provider has informed the nurse that she will be performing
an amniotomy on the client to induce labor. What is the nurses highest priority
intervention after the amniotomy is performed?
a. Applying clean linens under the woman
b. Taking the clients vital signs
c. Performing a vaginal examination
d. Assessing the fetal heart rate (FHR)
ANS: D
The FHR is assessed before and immediately after the amniotomy to detect any changes
that might indicate cord compression or prolapse. Providing comfort measures, such as
clean linens, for the client is important but not the priority immediately after an
amniotomy. The womans temperature should be checked every 2 hours after the rupture
of membranes but not the priority immediately after an amniotomy. The woman would
have had a vaginal examination during the procedure. Unless cord prolapse is suspected,
another vaginal examination is not warranted. Additionally, FHR assessment provides
clinical cues to a prolapsed cord.
10. The nurse who elects to work in the specialty of obstetric care must have
the ability to distinguish between preterm birth, preterm labor, and low birth weight.
Which statement regarding this terminology is correct?
a. Terms preterm birth and low birth weight
can be used interchangeably.
b. Preterm labor is defined as cervical
changes and uterine contractions
occurring between 20 and 37 weeks of
gestation.
c. Low birth weight is a newborn who
weighs below 3.7 pounds.
d. Preterm birth rate in the United States
continues to increase.
ANS: B
Before 20 weeks of gestation, the fetus is not viable (miscarriage); after 37 weeks, the
fetus can be considered term. Although these terms are used interchangeably, they have
different meanings: preterm birth describes the length of gestation (before 37 weeks),
regardless of the newborns weight; low birth weight describes only the infants weight at
the time of birth (2500 g or less), whenever it occurs. Low birth weight is anything below
2500 g or approximately pounds. In 2011, the preterm birth rate in the United States was
11.7 %; it has dropped every year since 2008.
11. The nurse is performing an assessment on a client who thinks she may be
experiencing preterm labor. Which information is the most important for the nurse to
understand and share with the client?
a. Because all women must be considered at
risk for preterm labor and prediction is so
variable, teaching pregnant women the
symptoms of preterm labor probably
causes more harm through false alarms.
b. Braxton Hicks contractions often signal
the onset of preterm labor.
c. Because preterm labor is likely to be the
start of an extended labor, a woman with
symptoms can wait several hours before
contacting the primary caregiver.
d. Diagnosis of preterm labor is based on
gestational age, uterine activity, and
progressive cervical change.
ANS: D
Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced
or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to
detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm
labor contractions, but they are not true labor. Waiting too long to see a health care
provider could result in essential medications failing to be administered. Preterm labor is
not necessarily long-term labor.
14. A number of methods can be used for inducing labor. Which cervical
ripening method falls under the category of mechanical or physical?
a. Prostaglandins are used to soften and thin
the cervix.
b. Labor can sometimes be induced with
balloon catheters or laminaria tents.
c. Oxytocin is less expensive and more
effective than prostaglandins but creates
greater health risks.
d. Amniotomy can be used to make the
cervix more favorable for labor.
ANS: B
Balloon catheters or laminaria tents are mechanical means of ripening the cervix.
Ripening the cervix, making it softer and thinner, increases the success rate of induced
labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a
greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce
labor only when the cervix is already ripe.
DIF: Cognitive Level: Understand REF: pp. 785-786 TOP: Nursing Process:
Planning
MSC: Client Needs: Health Promotion and Maintenance
21. What is the primary purpose for the use of tocolytic therapy to suppress
uterine activity?
a. Drugs can be efficaciously administered
up to the designated beginning of term at
37 weeks gestation.
b. Tocolytic therapy has no important
maternal (as opposed to fetal)
contraindications.
c. The most important function of tocolytic
therapy is to provide the opportunity to
administer antenatal glucocorticoids.
d. If the client develops pulmonary edema
while receiving tocolytic therapy, then
intravenous (IV) fluids should be given.
ANS: C
Buying time for antenatal glucocorticoids to accelerate fetal lung development may be
the best reason to use tocolytic therapy. Once the pregnancy has reached 34 weeks,
however, the risks of tocolytic therapy outweigh the benefits. Important maternal
contraindications to tocolytic therapy exist. Tocolytic-induced edema can be caused by IV
fluids.
22. When would an internal version be indicated to manipulate the fetus into a
vertex position?
a. Fetus from a breech to a cephalic
presentation before labor begins
b. Fetus from a transverse lie to a
longitudinal lie before a cesarean birth
c. Second twin from an oblique lie to a
transverse lie before labor begins
d. Second twin from a transverse lie to a
breech presentation during a vaginal birth
ANS: D
Internal version is used only during a vaginal birth to manipulate the second twin into a
presentation that allows it to be vaginally born. For internal version to occur, the cervix
needs to be completely dilated.
MULTIPLE RESPONSE
2. What are the complications and risks associated with cesarean births?
(Select all that apply.)
a. Pulmonary edema
b. Wound dehiscence
c. Hemorrhage
d. Urinary tract infections
e. Fetal injuries
ANS: A, B, C, D, E
Pulmonary edema, wound dehiscence, hemorrhage, urinary tract infections, and fetal
injuries are possible complications and risks associated with cesarean births.
3. Women who are obese are at risk for several complications during
pregnancy and birth. Which of these would the nurse anticipate with an obese client?
(Select all that apply.)
a. Thromboembolism
b. Cesarean birth
c. Wound infection
d. Breech presentation
e. Hypertension
ANS: A, B, C, E
A breech presentation is not a complication of pregnancy or birth for the client who is
obese. Venous thromboembolism is a known risk for obese women. Therefore, the use of
thromboembolism-deterrent (TED) hose and sequential compression devices may help
decrease the chance for clot formation. Women should also be encouraged to ambulate as
soon as possible. In addition to having an increased risk for complications with a
cesarean birth, in general, obese women are also more likely to require an emergency
cesarean birth. Many obese women have a pannus (i.e., large roll of abdominal fat) that
overlies a lower transverse incision made just above the pubic area. The pannus causes
the area to remain moist, which encourages the development of infection. Obese women
are more likely to begin pregnancy with comorbidities such as hypertension and type 2
diabetes.