1.
The nurse in charge is caring for a
patient who is in the first stage of labor. What is the shortest but most
difficult part of this stage?
a. Active phase
b. Complete phase
c. Latent phase
d. Transitional phase
a. Active phase
b. Complete phase
c. Latent phase
d. Transitional phase
Answer D
The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.
The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.
2.
The nurse is teaching a pregnant woman
with type 1 diabetes about her diet during pregnancy. Which client statement
indicates that the nurse's teaching was successful?
A) "I'll basically follow the same diet that I was following before I became pregnant."
B) "Because I need extra protein, I'll have to increase my intake of milk and meat."
C) "Pregnancy affects insulin production, so I'll need to make adjustments in my diet."
D) "I'll adjust my diet and insulin based on the results of my urine tests for glucose."
A) "I'll basically follow the same diet that I was following before I became pregnant."
B) "Because I need extra protein, I'll have to increase my intake of milk and meat."
C) "Pregnancy affects insulin production, so I'll need to make adjustments in my diet."
D) "I'll adjust my diet and insulin based on the results of my urine tests for glucose."
ANS;C
In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.
In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.
3.
Which factor would the nurse identify as
being most important in helping to reduce the maternal/fetal/neonatal
complications associated with pregnancy and diabetes?
A) Stability of the woman's emotional and psychological status
B) Degree of glycemic control achieved during the pregnancy
C) Evaluation of retinopathy by an ophthalmologist
D) Blood urea nitrogen level (BUN) within normal limits
A) Stability of the woman's emotional and psychological status
B) Degree of glycemic control achieved during the pregnancy
C) Evaluation of retinopathy by an ophthalmologist
D) Blood urea nitrogen level (BUN) within normal limits
ANS;B
Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state.
Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state.
4.
Because a pregnant client's diabetes has
been poorly controlled throughout her pregnancy, the nurse would be alert for
which of the following in the neonate at birth?
A) Macrosomia
B) Hyperglycemia
C) Low birthweight
D) Hypobilirubinemia
A) Macrosomia
B) Hyperglycemia
C) Low birthweight
D) Hypobilirubinemia
ANS;A
Poorly controlled diabetes during pregnancy can result in macrosomia due to hyperinsulinemia stimulated by fetal hyperglycemia. Typically the neonate is hypoglycemic due to the ongoing hyperinsulinemia that occurs after the placenta is removed. Infants of diabetic women typically are large and are at risk for hyperbilirubinemia due to excessive red blood cell breakdown.
Poorly controlled diabetes during pregnancy can result in macrosomia due to hyperinsulinemia stimulated by fetal hyperglycemia. Typically the neonate is hypoglycemic due to the ongoing hyperinsulinemia that occurs after the placenta is removed. Infants of diabetic women typically are large and are at risk for hyperbilirubinemia due to excessive red blood cell breakdown.
5.
A woman with diabetes is considering
becoming pregnant. She asks the nurse whether she will be able to take oral
hypoglycemics when she is pregnant. The nurse's response is based on the
understanding that oral hypoglycemics:
A) Can be used as long as they control serum glucose levels
B) Can be taken until the degeneration of the placenta occurs
C) Are usually suggested primarily for women who develop gestational diabetes
D) Show promising results but more studies are needed to confirm their effectiveness
A) Can be used as long as they control serum glucose levels
B) Can be taken until the degeneration of the placenta occurs
C) Are usually suggested primarily for women who develop gestational diabetes
D) Show promising results but more studies are needed to confirm their effectiveness
ANS;D
Several studies have used glyburide an oral hypoglycemic agent with promising results. However, more intensive research is needed to establish the drug's safety and efficacy during pregnancy.
Several studies have used glyburide an oral hypoglycemic agent with promising results. However, more intensive research is needed to establish the drug's safety and efficacy during pregnancy.
6.
A 10-week pregnant woman with diabetes has
a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should
be most concerned about which of the following possible fetal outcomes?
A) Congenital anomalies
B) Incompetent cervix
C) Placenta previa
D) Abruptio placentae
A) Congenital anomalies
B) Incompetent cervix
C) Placenta previa
D) Abruptio placentae
ANS;A
A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or abruptio placentae.
A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or abruptio placentae.
7.
After teaching a group of students about
the use of antiretroviral agents in pregnant women who are HIV-positive, the
instructor determines that the teaching was successful when the group
identifies which of the following as the underlying rationale?
A) Reduction in viral loads in the blood
B) Treatment of opportunistic infections
C) Adjunct therapy to radiation and chemotherapy
D) Can cure acute HIV/AIDS infections
A) Reduction in viral loads in the blood
B) Treatment of opportunistic infections
C) Adjunct therapy to radiation and chemotherapy
D) Can cure acute HIV/AIDS infections
ANS;A
Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS.
Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS.
8.
Assessment of a pregnant woman and her
fetus reveals tachycardia and hypertension. There is also evidence suggesting
vasoconstriction. The nurse would question the woman about use of which
substance?
A) Marijuana
B) Alcohol
C) Heroin
D) Cocaine
A) Marijuana
B) Alcohol
C) Heroin
D) Cocaine
ANS;D
Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant.
Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant.
9.
When teaching a class of pregnant women
about the effects of substance abuse during pregnancy, which of the following
would the nurse include?
A) Low-birth weight infants
B) Excessive weight gain
C) Higher pain tolerance
D) Longer gestational periods
A) Low-birth weight infants
B) Excessive weight gain
C) Higher pain tolerance
D) Longer gestational periods
ANS;A
Substance abuse during pregnancy is associated with low-birthweight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance abuse.
Substance abuse during pregnancy is associated with low-birthweight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance abuse.
10. A client who is HIV-positive is in her
second trimester and remains asymptomatic. She voices concern about her
newborn's risk for the infection. Which of the following statements by the
nurse would be most appropriate?
A) "You'll probably have a cesarean birth to prevent exposing your newborn."
B) "Antibodies cross the placenta and provide immunity to the newborn."
C) "Wait until after the infant is born and then something can be done."
D) "Antiretroviral medications are available to help reduce the risk of transmission."
A) "You'll probably have a cesarean birth to prevent exposing your newborn."
B) "Antibodies cross the placenta and provide immunity to the newborn."
C) "Wait until after the infant is born and then something can be done."
D) "Antiretroviral medications are available to help reduce the risk of transmission."
ANS;D
Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of delivery should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Waiting until after the infant is born may be too late.
Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of delivery should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Waiting until after the infant is born may be too late.
11.When assessing a
pregnant woman with heart disease throughout the antepartal period, the nurse
would be especially alert for signs and symptoms of cardiac decompensation at
which time?
A) 16 to 20 weeks' gestation
B) 20 to 24 weeks' gestation
C) 24 to 28 week's gestation
D) 28 to 32 week's gestation
A) 16 to 20 weeks' gestation
B) 20 to 24 weeks' gestation
C) 24 to 28 week's gestation
D) 28 to 32 week's gestation
ANS;D
A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation.
A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation.
12. When preparing a schedule of follow-up
visits for a pregnant woman with chronic hypertension, which of the following
would be most appropriate?
A) Monthly visits until 32 weeks, then bi-monthly visits
B) Bi-monthly visits until 28 weeks, then weekly visits
C) Monthly visits until 20 weeks, then bi-monthly visits
D) Bi-monthly visits until 36 weeks, then weekly visits
A) Monthly visits until 32 weeks, then bi-monthly visits
B) Bi-monthly visits until 28 weeks, then weekly visits
C) Monthly visits until 20 weeks, then bi-monthly visits
D) Bi-monthly visits until 36 weeks, then weekly visits
ANS;B
For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance.
For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance.
13. Which medication would the nurse question
if ordered to control a pregnant woman's asthma?
A) Budesonide
B) Albuterol
C) Salmeterol
D) Oral prednisone
A) Budesonide
B) Albuterol
C) Salmeterol
D) Oral prednisone
ANS;D
Oral corticosteroids such as prednisone are not preferred in the treatment of asthma during pregnancy. However, they can be used to treat severe asthma attacks during pregnancy. Budesonide, albuterol, and salmeterol are recommended for use during pregnancy to control asthma.
Oral corticosteroids such as prednisone are not preferred in the treatment of asthma during pregnancy. However, they can be used to treat severe asthma attacks during pregnancy. Budesonide, albuterol, and salmeterol are recommended for use during pregnancy to control asthma.
14. After teaching a pregnant woman with iron
deficiency anemia about her prescribed iron supplement, which statement
indicates successful teaching?
A) "I should take my iron with milk."
B) " I should avoid drinking orange juice."
C) "I need to eat foods high in fiber."
D) "I'll call the doctor if my stool is black and tarry."
A) "I should take my iron with milk."
B) " I should avoid drinking orange juice."
C) "I need to eat foods high in fiber."
D) "I'll call the doctor if my stool is black and tarry."
ANS; C
Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C-containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her doctor.
Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C-containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her doctor.
15. At which time should the nurse screen a
pregnant woman for group B streptococcus infection?
A) 16 weeks' gestation
B) 28 week' gestation
C) 32 weeks' gestation
D) 36 weeks' gestation
A) 16 weeks' gestation
B) 28 week' gestation
C) 32 weeks' gestation
D) 36 weeks' gestation
ANS; D
All pregnant women should be screened for group B streptococcus infection at 35 to 37 weeks' gestation.
All pregnant women should be screened for group B streptococcus infection at 35 to 37 weeks' gestation.
16.
The nurse is assessing a newborn of a
woman who is suspected of abusing alcohol. Which newborn finding would provide
additional evidence to support this suspicion?
A) Wide large eyes
B) Thin upper lip
C) Protruding jaw
D) Elongated nose
A) Wide large eyes
B) Thin upper lip
C) Protruding jaw
D) Elongated nose
ANS;B
Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities.
Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities.
17.
A nurse in the labor room is caring for a
client in the active phases of labor. The nurse is assessing the fetal patterns
and notes a late deceleration on the monitor strip. The most appropriate
nursing action is to:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion
Ans: 3
Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
18. After spontaneous rupture of membranes,
the nurse notices a prolapsed cord. The nurse immediately places the woman in
which position?
A) Supine
B) Side-lying
C) Sitting
D) Knee-chest
A) Supine
B) Side-lying
C) Sitting
D) Knee-chest
ANS;D
Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.
Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.
19. A primigravida whose labor was initially
progressing normally is now experiencing a decrease in the frequency and
intensity of her contractions. The nurse would assess the woman for which
condition?
A) A low-lying placenta
B) Fetopelvic disproportion
C) Contraction ring
D) Uterine bleeding
A) A low-lying placenta
B) Fetopelvic disproportion
C) Contraction ring
D) Uterine bleeding
ANS;B
The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.
The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.
20. The nurse would be alert for possible
placental abruption during labor when assessment reveals which of the
following?
A) Macrosomia
B) Gestational hypertension
C) Gestational diabetes
D) Low parity
A) Macrosomia
B) Gestational hypertension
C) Gestational diabetes
D) Low parity
ANS;B
Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.
Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.
21. Assessment of a woman in labor who is
experiencing hypertonic uterine dysfunction would reveal contractions that are:
A) Well coordinated
B) Poor in quality
C) Rapidly occurring
D) Erratic
A) Well coordinated
B) Poor in quality
C) Rapidly occurring
D) Erratic
ANS;D
Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality and lack sufficient intensity to dilate and efface the cervix. Contractions of precipitous labor occur rapidly such that labor is completed in less than three hours.
Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality and lack sufficient intensity to dilate and efface the cervix. Contractions of precipitous labor occur rapidly such that labor is completed in less than three hours.
22. A woman in labor is experiencing hypotonic
uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which
group of medications would the nurse expect to administer?
A) Sedatives
B) Tocolytics
C) Oxytocins
D) Corticosteroids
A) Sedatives
B) Tocolytics
C) Oxytocins
D) Corticosteroids
ANS;C
For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.
For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.
23. The fetus of a woman in labor is
determined to be in persistent occiput posterior position. Which of the
following would the nurse identify as the priority intervention?
A) Position changes
B) Pain relief measures
C) Immediate cesarean birth
D) Oxytocin administration
A) Position changes
B) Pain relief measures
C) Immediate cesarean birth
D) Oxytocin administration
ANS;B
Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.
Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.
24. A woman gave birth to a newborn via
vaginal delivery with the use of a vacuum extractor. The nurse would be alert
for which of the following in the newborn?
A) Asphyxia
B) Clavicular fracture
C) Caput succedaneum
D) Central nervous system injury
A) Asphyxia
B) Clavicular fracture
C) Caput succedaneum
D) Central nervous system injury
ANS;C
Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.
Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.
25. A pregnant client undergoing labor
induction is receiving an oxytocin infusion. Which of the following findings
would require immediate intervention?
A) Fetal heart rate of 150 beats/minute
B) Contractions every 2 minutes, lasting 45 seconds
C) Uterine resting tone of 14 mm Hg
D) Urine output of 20 mL/hour
A) Fetal heart rate of 150 beats/minute
B) Contractions every 2 minutes, lasting 45 seconds
C) Uterine resting tone of 14 mm Hg
D) Urine output of 20 mL/hour
ANS;D
Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minutes. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention.
Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minutes. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention.
26. A woman with a history of crack cocaine
abuse is admitted to the labor and birth area. While caring for the client, the
nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen
reveals an irregular wall contour. The client also complains of acute abdominal
pain that is continuous. Which of the following would the nurse suspect?
A) Amniotic fluid embolism
B) Shoulder dystocia
C) Uterine rupture
D) Umbilical cord prolapse
A) Amniotic fluid embolism
B) Shoulder dystocia
C) Uterine rupture
D) Umbilical cord prolapse
ANS;C
Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.
Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.
27. When assessing several women for possible
VBAC, which woman would the nurse identify as being the best candidate?
A) One who has undergone a previous myomectomy
B) One who had a previous cesarean birth via a low transverse incision
C) One who has a history of a contracted pelvis
D) One who has a vertical incision from a previous cesarean birth
A) One who has undergone a previous myomectomy
B) One who had a previous cesarean birth via a low transverse incision
C) One who has a history of a contracted pelvis
D) One who has a vertical incision from a previous cesarean birth
B
VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.
VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.
28. A woman is to undergo an amnioinfusion.
Which statement would be most appropriate to include when teaching the woman
about this procedure?
A) "You'll need to stay in bed while you're having this procedure."
B) "We'll give you an analgesic to help reduce the pain."
C) "After the infusion, you'll be scheduled for a cesarean birth."
D) "A suction cup is placed on your baby's head to help bring it out."
A) "You'll need to stay in bed while you're having this procedure."
B) "We'll give you an analgesic to help reduce the pain."
C) "After the infusion, you'll be scheduled for a cesarean birth."
D) "A suction cup is placed on your baby's head to help bring it out."
ANS;A
An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer's lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth.
An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer's lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth.
29. Which finding would indicate to the nurse
that a woman's cervix is ripe in preparation for labor induction?
A) Posterior position
B) Firm
C) Closed
D) Shortened
A) Posterior position
B) Firm
C) Closed
D) Shortened
ANS;D
A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.
A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.
30. A woman with preterm labor is receiving
magnesium sulfate. Which finding would require the nurse to intervene
immediately?
A) Respiratory rate of 16 breaths per minute
B) Diminished deep tendon reflexes
C) Urine output of 45 mL/hour
D) Alert level of consciousness
A) Respiratory rate of 16 breaths per minute
B) Diminished deep tendon reflexes
C) Urine output of 45 mL/hour
D) Alert level of consciousness
ANS;B
Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.
Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.
31. A woman who is 42 weeks pregnant comes to
the clinic. Which of the following would be most important?
A) Determining an accurate gestational age
B) Asking her about the occurrence of contractions
C) Checking for spontaneous rupture of membranes
D) Measuring the height of the fundus
A) Determining an accurate gestational age
B) Asking her about the occurrence of contractions
C) Checking for spontaneous rupture of membranes
D) Measuring the height of the fundus
ANS; A
Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.
Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.
32. After teaching a couple about what to
expect with their planned cesarean birth, which statement indicates the need
for additional teaching?
A) "Holding a pillow against my incision will help me when I cough."
B) "I'm going to have to wait a few days before I can start breast-feeding."
C) "I guess the nurses will be getting me up and out of bed rather quickly."
D) "I'll probably have a tube in my bladder for about 24 hours or so."
A) "Holding a pillow against my incision will help me when I cough."
B) "I'm going to have to wait a few days before I can start breast-feeding."
C) "I guess the nurses will be getting me up and out of bed rather quickly."
D) "I'll probably have a tube in my bladder for about 24 hours or so."
ANS;B
Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.
Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.
33. A client arrives at a birthing center in
active labor. Her membranes are still intact, and the nurse-midwife prepares to
perform an amniotomy. A nurse who is assisting the nurse-midwife explains to
the client that after this procedure, she will most likely have:
1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure monitoring
1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure monitoring
Answer: 2
Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
34. A nurse is monitoring a client in labor.
The nurse suspects umbilical cord compression if which of the following is
noted on the external monitor tracing during a contraction?
1.Early decelerations
2.Variable decelerations
3.Late decelerations
4.Short-term variability
1.Early decelerations
2.Variable decelerations
3.Late decelerations
4.Short-term variability
Ans: 2
Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
35. A primipara client gave birth vaginally to
a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus,
expecting it to be:
A) Two fingerbreadths above the umbilicus
B) At the level of the umbilicus
C) Two fingerbreadths below the umbilicus
D) Four fingerbreadths below the umbilicus
A) Two fingerbreadths above the umbilicus
B) At the level of the umbilicus
C) Two fingerbreadths below the umbilicus
D) Four fingerbreadths below the umbilicus
ANS;B
During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus.
During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus.
36. When caring for a mother who has had a
cesarean birth, the nurse would expect the client's lochia to be:
A) Greater than after a vaginal delivery
B) About the same as after a vaginal delivery
C) Less than after a vaginal delivery
D) Saturated with clots and mucus
A) Greater than after a vaginal delivery
B) About the same as after a vaginal delivery
C) Less than after a vaginal delivery
D) Saturated with clots and mucus
ANS;C
Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.
Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.
37. The nurse is developing a teaching plan
for a client who has decided to bottle feed her newborn. Which of the following
would the nurse include in the teaching plan to facilitate suppression of lactation?
A) Encouraging the woman to manually express milk
B) Suggesting that she take frequent warm showers to soothe her breasts
C) Telling her to limit the amount of fluids that she drinks
D) Instructing her to apply ice packs to both breasts every other hour
A) Encouraging the woman to manually express milk
B) Suggesting that she take frequent warm showers to soothe her breasts
C) Telling her to limit the amount of fluids that she drinks
D) Instructing her to apply ice packs to both breasts every other hour
ANS;D
If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.
If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.
38. The nurse is making a follow-up home visit
to a woman who is 12 days postpartum. Which of the following would the nurse
expect to find when assessing the client's fundus?
A) Cannot be palpated
B) 2 cm below the umbilicus
C) 6 cm below the umbilicus
D) 10 cm below the umbilicus
A) Cannot be palpated
B) 2 cm below the umbilicus
C) 6 cm below the umbilicus
D) 10 cm below the umbilicus
ANS;A
By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
39. A client who is breast-feeding her newborn
tells the nurse, "I notice that when I feed him, I feel fairly strong
contraction-like pain. Labor is over. Why am I having contractions now?"
Which response by the nurse would be most appropriate?
A) "Your uterus is still shrinking in size; that's why you're feeling this pain."
B) "Let me check your vaginal discharge just to make sure everything is fine."
C) "Your body is responding to the events of labor, just like after a tough workout."
D) "The baby's sucking releases a hormone that causes the uterus to contract."
A) "Your uterus is still shrinking in size; that's why you're feeling this pain."
B) "Let me check your vaginal discharge just to make sure everything is fine."
C) "Your body is responding to the events of labor, just like after a tough workout."
D) "The baby's sucking releases a hormone that causes the uterus to contract."
ANS;D
The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.
The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.
40 When the nurse is assessing a postpartum
client approximately 6 hours after delivery, which finding would warrant
further investigation?
A) Deep red, fleshy-smelling lochia
B) Voiding of 350 cc
C) Heart rate of 120 beats/minute
D) Profuse sweating
A) Deep red, fleshy-smelling lochia
B) Voiding of 350 cc
C) Heart rate of 120 beats/minute
D) Profuse sweating
ANS;C
Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.
Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.
41 A postpartum client who is bottle feeding
her newborn asks, "When should my period will return?" Which response
by the nurse would be most appropriate?
A) "It's difficult to say, but it will probably return in about 2 to 3 weeks."
B) "It varies, but you can estimate it returning in about 7 to 9 weeks."
C) "You won't have to worry about it returning for at least 3 months."
D) "You don't have to worry about that now. It'll be quite a while."
A) "It's difficult to say, but it will probably return in about 2 to 3 weeks."
B) "It varies, but you can estimate it returning in about 7 to 9 weeks."
C) "You won't have to worry about it returning for at least 3 months."
D) "You don't have to worry about that now. It'll be quite a while."
ANS;B
For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.
For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.
42. The nurse interprets which of the
following as evidence that a client is in the taking-in phase?
A) Client states, "He has my eyes and nose."
B) Client shows interest in caring for the newborn.
C) Client performs self-care independently.
D) Client confidently cares for the newborn.
A) Client states, "He has my eyes and nose."
B) Client shows interest in caring for the newborn.
C) Client performs self-care independently.
D) Client confidently cares for the newborn.
ANS;A
During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.
During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.
43. Which of the following would the nurse
interpret as being least indicative of paternal engrossment?
A) Demonstrating pleasure when touching or holding the newborn
B) Identifying imperfections in the newborn's appearance
C) Being able to distinguish his newborn from others in the nursery
D) Showing feelings of pride with the birth of the newborn
A) Demonstrating pleasure when touching or holding the newborn
B) Identifying imperfections in the newborn's appearance
C) Being able to distinguish his newborn from others in the nursery
D) Showing feelings of pride with the birth of the newborn
ANS;B
Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.
Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.
44. A postpartum client comes to the clinic
for her 6-week postpartum check-up. When assessing the client's cervix, the
nurse would expect the external cervical os to appear:
A) Shapeless
B) Circular
C) Triangular
D) Slit-like
A) Shapeless
B) Circular
C) Triangular
D) Slit-like
ANS;D
The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."
The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."
45. The nurse teaches a postpartum client how
to do Kegel exercises for which reason?
A) Reduce lochia
B) Promote uterine involution
C) Improve pelvic floor tone
D) Alleviate perineal pain
A) Reduce lochia
B) Promote uterine involution
C) Improve pelvic floor tone
D) Alleviate perineal pain
ANS;C
Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.
Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.
46. A father of a newborn tells the nurse,
"I may not know everything about being a dad, but I'm going to do the best
I can for my son." The nurse interprets this as indicating the father is
in which stage of adaptation?
A) Expectations
B) Transition to mastery
C) Reality
D) Taking-in
A) Expectations
B) Transition to mastery
C) Reality
D) Taking-in
ANS;B
The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.
The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.
47. A postpartum client is experiencing
subinvolution. When reviewing the woman's labor and birth history, which of the
following would the nurse identify as being least significant to this
condition?
A) Early ambulation
B) Prolonged labor
C) Large fetus
D) Use of anesthetics
A) Early ambulation
B) Prolonged labor
C) Large fetus
D) Use of anesthetics
ANS;A
Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.
Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.
48. Which of the following would lead the
nurse to suspect that a postpartum woman is having a problem?
A) Elevated white blood cell count
B) Acute decrease in hematocrit
C) Increased levels of clotting factors
D) Pulse rate of 60 beats/minute
A) Elevated white blood cell count
B) Acute decrease in hematocrit
C) Increased levels of clotting factors
D) Pulse rate of 60 beats/minute
ANS;B
Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding.
The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.
Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding.
The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.
49. A woman who gave birth 24 hours ago tells
the nurse, "I've been urinating so much over the past several hours."
Which response by the nurse would be most appropriate?
A) "You must have an infection, so let me get a urine specimen."
B) "Your body is undergoing many changes that cause your bladder to fill quickly."
C) "Your uterus is not contracting as quickly as it should."
D) "The anesthesia that you received is wearing off and your bladder is working again."
A) "You must have an infection, so let me get a urine specimen."
B) "Your body is undergoing many changes that cause your bladder to fill quickly."
C) "Your uterus is not contracting as quickly as it should."
D) "The anesthesia that you received is wearing off and your bladder is working again."
ANS;B
Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.
Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.
50. A woman who is 12 hours postpartum had a
pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a
pulse of 60 beats per minute. Which of these actions should the nurse take?
A) Document the finding, as it is a normal finding at this time.
B) Contact the physician, as it indicates early DIC.
C) Contact the physician, as it is a first sign of postpartum eclampsia.
D) Obtain an order for a CBC, as it suggests postpartum anemia.
A) Document the finding, as it is a normal finding at this time.
B) Contact the physician, as it indicates early DIC.
C) Contact the physician, as it is a first sign of postpartum eclampsia.
D) Obtain an order for a CBC, as it suggests postpartum anemia.
ANS;A
As a result of the changes in blood volume and cardiac output after delivery, relative bradycardia may be noted. The woman's pulse rate may range from 50 to 70 beats per minute.
As a result of the changes in blood volume and cardiac output after delivery, relative bradycardia may be noted. The woman's pulse rate may range from 50 to 70 beats per minute.
