a client in the 28th week gestation comes to the emergency department because she thinks that she is in labor
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A client in the 28th week gestation comes to the emergency department
because she thinks that she is
1. A client in the 28th week gestation comes to the emergency department because she thinks
that she is in labor. To confirm a diagnosis of preterm labor, the nurse would expect physical
examination to reveal:
a. Irregular uterine contractions with no cervical dilatation
b. Painful contractions with no cervical dilatation
c. Regular uterine contractions with cervical dilatation
d. Regular uterine contractions with no cervical dilatation
Ans: C – regular uterine contractions (every 10 minutes or more) along with cervical
dilation before 36 weeks’ gestation or rupture of fluids indicates preterm labor. Uterine
contractions without cervical change don’t indicate preterm labor.
2. A client in the active phase of labor has reactive fetal monitor strip and has been
encouraged to walk. When she returns to bed for a monitor check, she complains of an urge
to push. When performing vaginal examination, the nurse accidentally ruptures the amniotic
membranes, the umbilical cord comes out. What should be done next?
a. Put the client in a knee-chest position
b. Call the physician or midwife
c. Push down on the uterine fundus
d. Set up for a fetal blood sampling to assess for fetal acidosis
Ans: A – the knee–to–chest position gets the weight off the baby and umbilical cord, which
would prevent blood flow. Calling d physician or midwife and setting up for blood sampling is
important, but they have a lower priority than getting d baby off the cord. Pushing down on d
fundus would increase d danger by further compromising blood flow.
3. A client is attempting to deliver vaginally despite the fact that her previous delivery was by
cesarean section. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100 seconds.
Suddenly, the client complaints of intense abdominal pain and the fetal monitor stops picking
up contractions. The nurse recognizes that which of the following has occurred?
a. Abruptio placentae
b. Prolapsed cord
c. Partial placenta previa
d. Complete uterine rupture
Ans: D – in complete uterine rupture, the client would feel a sharp pain in the lower abdomen
and contractions would cease. Fetal heart rate would also cease within a few minutes. Uterine
irritability would continue to be indicated by the fetal heart monitor tracing with abruption
placentae. With a prolapsed cord, contractions would continue and there would be no pain
from d prolapse itself. There would be vaginal bleeding with a partial placenta previa, but no
pain outside of the expected pain of contractions.
4. A client with gravida 3 para 2 at 40 weeks gestation is admitted with spontaneous
contractions. The physician performs an amniotomy to augment her labor. The priority
nursing action is to:
a. Explain the rationale for the amniotomy to the client
b. Assess fetal heart tones after the amniotomy
,A client in the 28th week gestation comes to the emergency department
because she thinks that she is
c. Ambulate the client to strengthen the contraction pattern
d. Position the client in a lithotomy position to administer perineal care
Ans: B - the nurse should assess fetal heart tones. After an amniotomy is performed, the
umbilical cord may be washed down below the presenting part and cause umbilical cord
compression, which would be indicated by variable deceleration on the fetal heart tracing. An
explanation of the rationale for amniotomy would be given before d procedure. After assessing
the fetal response to the amniotomy, perineal care s provided. The nurse would ambulate
client only if the presenting part were engaged.
5. The nurse can consider the fetus’s head to be engaged when:
a. The presenting part moves through the pelvis
b. The fetal head rotates to pass through the ischial spines
c. The fetal head extends as it passes under the symphysis pubis
d. The biparietal diameter passes the pelvic inlet
Ans: D – d fetus’s head s considered engaged when the biparietal diameter passes d pelvic inlet.
The presenting part moving through d pelvis s called descent. The head flexing so that the chin
moves closer to d chest s called flexion. Rotation of the head to pass through the ischial spines
is called internal rotation. Extension of the head as it passes under d symphysis pubis s called
extension.
6. A client is experiencing true labor when her contraction pattern shows:
a. Occasional irregular contractions
b. Irregular contractions that increase in intensity
c. Regular contractions that remain the same
d. Regular contractions that increase in frequency and duration
Ans: D- regular contractions that increase in frequency and duration as well as intensity indicate
true labor. The other choices don’t describe d contraction pattern of true labor.
7. A client is admitted to the hospital with contractions that are about 1 to 2 minutes apart
and reveal that her cervix is dilated 8 cm. The client is in which stage of labor?
a. Latent phase
b. Active phase
c. Third stage
d. Transitional phase
Ans: D- d client is in d transitional phase of labor. This phase of labor is characterized by cervical
dilation of 8 to 10 cm and contractions that are about 1 to 2 minutes apart and last for 60 to 90
seconds with strong intensity. In the latent phase, the cervix is dilated 0 to 3 cm and
contractions are irregular. During the active phase, the cervix is dilated to 4 to 7 cm and
contractions are about 5 to 8 minutes apart and last 45 to 60 seconds with moderate to strong
intensity. The 3rd stage of labor extends from delivery of the neonate to expulsion of the
placenta and lasts from 5 to 30 minutes.
8. A client in the second stage of labor experiences rupture of membranes. The most
appropriate intervention by the nurse is to:
,A client in the 28th week gestation comes to the emergency department
because she thinks that she is
a. Assess the client’s vital signs immediately
b. Observe for prolapsed cord and monitor fetal heart rate
c. Administer oxygen through a face mask at 6-10 L per min
d. Position the client on her side
Ans: B – the nurse should immediately check for prolapsed cord and monitor FHR. When the
membranes rupture, the cord may become compressed between the fetus and maternal cervix
or pelvis, thus compromising fetoplacental perfusion. It isn’t necessary to position the client on
her left side, monitor maternal vital signs, or administer oxygen when the client’s membrane
rupture.
9. A client in labor is being monitored by an internal electronic device to evaluate fetal
station. The nurse measures the duration of her contractions by:
a. Measuring from the beginning of the increment to the end of the decrement
b. Measuring from the beginning of one contraction to the beginning of the next
c. Measuring from the beginning of the decrement to the end of the increment
d. Using an intrauterine catheter that measures increases in contraction
Ans: A- the duration of a contraction is measured from the beginning of the increment to the
end of the decrement. Measuring from the beginning of one contraction to the beginning of the
next reveals frequency. Measuring from the beginning of one contraction to the beginning of
the next reveals frequency. Measuring during the acme phase of a contraction reveals intensity
(measured with an intrauterine catheter or by palpation).
10. A client is receiving magnesium sulfate to help suppress preterm labor. The nurse
should watch for which sign of magnesium toxicity?
a. Headache
b. Loss of deep tendon reflexes
c. Palpitations
d. Dyspepsia
Ans: B – magnesium toxicity causes signs of central nervous system depression, such as loss of
deep tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision,
slurred speech, and confusion. Headache may be an adverse effect of calcium channel blockers,
which are sometimes used to treat preterm labor. Palpitations are an adverse effect of
terbutaline and ritodrine, which are also used to treat preterm labor. Dyspepsin may occur as
an adverse effect of indomethacin, a prostaglandin synthesize inhibitor, used to suppress
preterm labor.
11. When assessing a postpartum client for uterine bleeding, the nurse finds the fundus to be
boggy. After fundal massage, the physician prescribes 0.2 mg of methylergonovine
(Methergine) by mouth. What should the nurse tell the client?
a. “Methergine is commonly used to help the uterus contract so that the bleeding will
decrease. You may experience more cramping as your uterus becomes firmer.”
, A client in the 28th week gestation comes to the emergency department
because she thinks that she is
b. “You will probably take this medication until you are discharged from the hospital.
Every patient usually needs to take this medication.”
c. “If your blood pressure is low, you won’t be able to take this medication; I will establish a
new IV line so I can start Pitocin again.”
d. “Most people don’t experience additional pain or cramping from taking this medication.”
Ans: A – Methylergonovine, an ergot alkaloid, is commonly given to stimulate sustained
uterine contraction. It allows the uterus to remain contracted and firm, thus decreasing
postpartum bleeding. Abdominal cramping, which may become painful, is a common adverse
effect.
Methergine is discontinued when the lochia flow has decreased or the client complains of severe
cramping. Clients may need only a few doses of Methergine to keep the uterus contracted.
Taking Methergine is contraindicated in clients with hypertension.
12. The nurse is providing care for a postpartum client. Which of the following conditions
would place this client at greater risk for postpartum hemorrhage?
a. Hypertension
b. Uterine infection
c. Placenta previa
d. Severe pain
Ans: C – d client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta
previa, the lower uterine segment doesn’t contract as well as the fundal part of the uterus;
therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don’t place
the client at increased risk for postpartum hemorrhage.
13. A client has delivered twins. What is the most important intervention for the nurse
to perform?
a. Assess fundal tone and lochia flow
b. Apply a cold pack to the perineal area
c. Administer analgesics as ordered
d. Encourage voiding by offering the bedpan
Ans: A – women who experience a twin delivery are at a higher risk for postpartum
hemorrhage due to overdistention of d uterus, which causes uterine atony. Assessing fundal
tone and lochia flow helps to determine risks for hemorrhage. Applying cold packs to d
perineum, administering analgesics as ordered, and offering d bedpan r all significant nursing
interventions, however, detecting and preventing postpartum hemorrhage s most important.
14. Which of the following is a normal physiological response in the early postpartum period?
a. Urinary urgency and dysuria
b. Rapid diuresis
c. Decrease in blood pressure
d. Increased motility of the GI system
Ans: B – in d early postpartum period there s an increase in the glomerular filtration rate and a
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