MCN - Midterm Exam Review

What is the intensity of uterine contractions if the fundus is firm and difficult to indent by pressing the fingertips?
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Terms in this set (159)
What is the smallest anteroposterior diameter of the fetal skull?suboccipitobregmaticWhich is considered as the normal fetal attitude in cephalic presentation?Complete FlexionThe movement of the passenger through the birth canal is determined by several interacting factors namely, the fetal head, attitude, lie, presentation and position.TrueWhich factor affecting labor and birth process composed of rigid bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and introitus?PassageWhich fetal position is considered as the most common?LOAWhat is known as the largest part of the fetus?HeadSecondary power is used by the woman during the first stage of labor for an effective cervical dilatation and effacement.FalseThe upper portion of the uterus is passive and the lower uterine segment becomes active during uterine contractions.FalseWhat causes the effacement and dilatation of the cervix and descent of the fetus?primary powerWhat hormone is responsible for the softening of cartilage in the pelvis during labor & delivery?RelaxinApproximately 8% of women at term experience rupture of the amniotic membranes before the onset of labor.8%Blood flow is decreased to the fetus at the peak of each contraction, which leads to a low in pH status.TrueWhich of the following is the sign of true labor? a. Pains usually occur in the abdomen b. Intervals between contractions gradually shorten c. Rest and warm tub bath lessen contractions d. No change in the cervixb. Intervals between contractions gradually shortenApproximately how many lbs is loss during labor and delivery of a mother?1-3 lbsWhat danger might occur if amniotic membranes rupture while engagement has not yet occured?prolapse cordThe best position for a woman in labor.lateralWhat food can you offer to a woman in labor?sips of fluid or ice cubes or hard candy for fast fluid and calorie absorptionAmniotic membranes, once labor is well established can be ruptured through:amniotomyIn primiparas, lightening or descent of the fetal presenting part into the pelvis occurs approximately how many week/s before term?2 weeksIf labor has not spontaneously occurred within 24 hours after membrane rupture and the pregnancy is at term, labor is induced to help reduce these risks.TrueThe sudden burst of energy of the mother is physiologically related to:increase epinephrine which is caused by decreased in progesteroneMother's inability/difficulty to urinate during labor can be caused by:pressure of the fetal head as it descends to the birth canal against the anterior bladderThe surest sign that labor has begun is progressive uterine contractions.TrueSigns of true labor do not involve uterine and cervical changes.FalseThe client's BP commonly increases during what stages of labor because of the contractions?first and second stagesThroughout pregnancy, the cervix feels softer than normal, similar to the consistency of an earlobe. What do you call this sign?Goodell's signLightening probably occurs early in primiparas because of tight abdominal muscles.trueTrue labor contractions are usually felt in the abdomen or inguinal region.falseBloody show is considered a sign that labor will begin within 24 - 48 hrs.trueA nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care?Defer vaginal examinations.A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation? (Select all that apply.) a.Softening of the lower uterine segment b.Lengthening of the umbilical cord c.Swift gush of clear amniotic fluid d.Appearance of white discharge from the vaginaLengthening of the umbilical cordA nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? a.Sacral counterpressure b.Abdominal effleurage c.Showering if not contraindicated d.Back rub and massageShowering if not contraindicatedA nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? a.Back rub and massage b.Abdominal effleurage c.Sacral counterpressure d.Showering if not contraindicatedc.Sacral counterpressureA nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? a.Encourage the client to take deep, cleansing breaths. b.Prepare to remove a fecal impaction. c.Assist the client to the bathroom. d.Prepare for an impending delivery.d.Prepare for an impending delivery.A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? a.Encourage the mother to void b.Elevate the mother's legs c.Push on the uterus to assist in expressing clots d.Massage the fundus until it is firmMassage the fundus until it is firmAfter the baby's head extends, which of these actions should be carried out first? a.Feel the nape for any cord coil. b.Stimulate cry. c.Suction the nose and then the mouth. d.Promote internal rotation of the head.a.Feel the nape for any cord coil.Anesthetic agents alter the transmission of impulses to the bladder. a.False b.TrueTrueCervical dilatation during the latent phase of the first stage of labor.0-3cmDuring ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?A normal postural discharge of lochiaIt is believed that tranquilizers increase the level of anxiety of a woman.FalseMultigravida Zeny has been in labor for five hours. After an internal examination, the nurse tells the client she is now beginning the second stage of labor. The nurse realizes the client understands this stage when she says: a."My cervix is completely dilated." b."My membranes are now ruptured." c."I'm having bloody show." d."The contractions are intense.""My cervix is completely dilated."Normal labor, consists of regular progression of uterine contractions.TruePassage of the fetus through birth canal involves different position changes. Place the position changes below in sequence that they occur: A. Internal rotation B. Descent C. Flexion D. External rotation E. Extension F. Expulsion. a. BCAEDF b. BCADEF c. BACDEF d. Internal rotation, B. Descent,C. Flexion, D. External rotation, E. Extension, and F. Expulsion. e. BACDEFBACDEFThe first stage of labor is also known as the stage of dilatation.TrueThis refers to the amount of pain one is willing to endure.Pain ToleranceThis refers to the injection of an anesthetic agent into the intracutaneous, subcutaneous, and intramuscular areas of the perineum.Local Infiltration AnesthesiaWhen assessing fetal heart rate status during labor, Nurse Pilita notes late decelerations with tachycardia and decreasing variability. What action should she take? a.Report findings to the physician. b.Decrease IV fluids. c.Continue monitoring because this is a normal occurrence. d.Turn the client on her right side.Report findings to the physician.While shopping in a mall, you hear a multiparous woman say loudly, "I think my baby's coming." After asking someone to call 911, you assist the client to deliver a term neonate. While waiting for the ambulance, you suggest that the mother initiate breastfeeding primarily to: a.Prevent neonatal hypoglycemia b.Contract the mother's uterus. c.Begin the parental-infant bonding process. d.Provide fluids to the neonate.Contract the mother's uterus.You just received a client in the delivery room. On assessment the baby's head is crowning and she is bearing down, and delivery appears imminent. The nurse should BEST: a. Transfer her immediately by stretcher to the delivery room. b. Instruct the client to pant during contractions and to breathe through her mouth. c. Tell her to breathe through her mouth and not to bear down. d. Support the perineum with the hand to prevent tearing and tell the client to pant.Support the perineum with the hand to prevent tearing and tell the client to pant.When to measure the RR and BP of a client in labor? a.before uterine contractions b.during uterine contractions c.during the active phase of labor d.between uterine contractionsbetween uterine contractionsTo determine the strength of uterine contraction and the nurse is assessing manually, rate the contraction as mild, moderate, and strong at the ____. a.end of the uterine contraction b.beginning of the uterine contraction c.peak of the uterine contraction d.all of the choicespeak of the uterine contractionWhat is the first sign of placental separation? a.Lengthening of the umbilical cord b.Uterus becomes firm and globular in shape c.Sudden gush of blood from the vagina d.Uterine fundus rises in the abdomenUterus becomes firm and globular in shapeWhen the amniotic membranes have ruptured, temperature is assessed every ____. a.30 minutes depending on the discretion of the health care provider b.15 minutes c.4 hours d.1 to 2 hours depending on the policy of the institution1 to 2 hours depending on the policy of the institutionWhich client's manifestation upon admission that a vaginal examination must be done immediately? interval of 4 mins b.+1 station urge to bear down d.frequency of contractions is 4-5 minsan urge to bear downWhich position during labor increases the pelvic diameter? a.sitting b.standing c.side lying d.hands and kneessittingIf you are assigned to assess the progress of uterine contractions at the labor room, use a light touch on the woman's abdomen while timing the contractions or estimating the strength manually. If contractions begin at 9:00, 9:06, and 9:12, their frequency is every ___. a.6 mins b.5 mins c.4 mins d.3 mins6 minsIf the woman's BOW ruptured at home, the nurse should ask her to describe the color of amniotic fluid. A yellow-stained amniotic fluid may indicate ____. a.prematurity b.blood incompatibility c.infection d.respiratory distress syndromeblood incompatibilityIf the cervix is not completely dilated, the student nurse can encourage clients avoid involuntary pushing during contractions through ___. a.meditation b.pant-blow breathing c.back rub d.analgesic administrationpant-blow breathingWhat is the technique used in delivering the placenta? a.controlled cord traction with counter traction b.all of the choices c.Ritgen's maneuver d.controlled traction of the umbilical cordcontrolled cord traction with counter tractionWhich statement pertains to a meconium staining amniotic fluid? a.It is not a significant finding during the second stage of labor. b.In a vertex presentation it may indicate fetal anoxia. c.It is a sign of maternal infection. d.It is normal in breech presentation because of head compression.In a vertex presentation it may indicate fetal anoxia.Uterine contractions may be monitored intermittently by hand or continuously by an external electronic monitor. a.False b.TrueTrueFor the fetus in vertex presentation to pass through the birth canal, the fetal head and body must adjust to the passage by certain positional changes known as _____. a.synclitism b.cardinal movements c.engagement d.stationb. cardinal movementsWhich drug is administered to the mother 1 min. after the delivery of the baby? a.methergine b.carboprost c.cytotec d.oxytocind.oxytocinWhich allows the delivery of the fetal head in a vertex presentation? a.flexion b.expulsion c.extension d.external rotationextensionWhich of the following controls the rate at which the head is born and prevents laceration? a.McRoberts maneuver b.Ritgen's maneuver c.Fundal pressureRitgen's maneuverThe third stage of labor should be completed within how many minutes after the birth of the baby? a.60 mins b.30-45 mins c.15-35 mins d.30 mins30 minsWhich nursing intervention is done right after the delivery of the placenta to promote uterine contraction and prevent hemorrhage? a.administer oxytocin b.cold pack application c.all of the choices d.fundal massagefundal massageThe initial intrapartum assessment is useful in categorizing the woman as to her risk for having difficulty in labor or fetal risk for needing special care at birth. a.True b.FalseTrueWhen to perform cord clamping of the newborn? a.after the 5 mins APGAR scoring b.1-3 mins after birth c.after spontaneous breathing occur d.1-4 mins after birthb.1-3 mins after birthTrue or False. New mothers often experience conflicting feelings of joy and emotional letdown during the first few weeks after birth, often called the Postpartum blues or baby blues.TrueTrue or False. The second day after birth is potentially the most dangerous time for a woman.FalseTrue or False. The immediate postpartal period is a time during which a couple deny the new role and resist to fit their expectations for that role.FalseTrue or False. Many mothers may feel abandoned and less important after giving birth than they did during pregnancy or labor.TrueTrue or False. Pregnancy hormones begin to increase as soon as the placenta is no longer present.FalseTrue or False. The postpartum period is a time of transition during which a couple gives up concepts such as "childless" or "parents of one".TrueTrue or False. Postpartal Period or Puerperium came from latin word puera "child" and parera "to bring forth".FalseTrue or False. In LETTING GO PHASE, the woman begins to take a stronger interest in her infant and begins maternal role behaviors.FalseTrue or False. Mothers in TAKING HOLD PHASE gave up their ideal birth experience and reconcile it with what really occurred.FalseTrue or False. TAKING IN PHASE's primary focus is on recovery from birth and her need for food, fluids and deep restorative sleep.TrueTrue or False. A well-contracted fundus feels so firm it can be compared with a grapefruit in both size and tenseness.TrueTrue or False. Maternal role attainment is the process by which a woman learns mothering behaviors and becomes comfortable with her identity as a mother.TrueTrue or False. The uterus of a breastfeeding mother may contract even more quickly, because progesterone, which is released with breastfeeding, stimulates uterine contractions.FalseTrue or False. Digestion and absorption begin to be active again soon after birth unless a woman has had a cesarean delivery.TrueTrue or False. Extensive diaphoresis and diuresis begin almost immediately after birth to rid the body of this fluid.TrueTrue or False. TAKING IN PHASE is the time when the new parents review their pregnancy and the labor and birth.TrueTrue or False. The Formal Stage of Maternal Goal Attainment begins when the mother begins to make her own choices about mothering.FalseTrue or False. Usual blood loss with a vaginal birth is 1,300 to 1,500 ml.FalseTrue or False. Anticipatory guidance and individualized support from health care personnel are important to help the parents understand that this response is normal.TrueTrue or False. In the third phase, called TAKING IN, a woman finally redefines her new role.FalseTrue or False. Nurses help prevent engorgement by assisting women to begin breastfeeding early and to feed frequently.TrueTrue or False. At the time fo delivery and the baby is crying and breathing normally, we avoid any manipulation, such as routine suctioning.TrueTrue or False. At the time of delivery and the baby is crying and breathing normally, we avoid any manipulation, such as routine suctioning.TrueTrue or False. The instillation of eye prophylaxis may be delayed up to 1hour after birth to allow eye contact during parent newborn bonding.TrueTrue or False. A neutral thermal environment is best achieved by performing the newborn assessment and interventions with the newborn unclothed and under a radiant warmer.TrueTrue or False. Normal temperature of a newborn is 36.4 to 37.2 degree celsius.TrueTrue or False. Bathing should be delayed until 24 hours after birth.TrueTrue or False. The umbilical cord pulsates for a moment after the infant is born as last flow of blood passes from placenta into the infant.TrueTrue or False. Brief periods of apnea after delivery, lasting only for 5 to 10 seconds with no color or heart rate changes, are considered normal.TrueTrue or False. Calling out of the time of birth is being done within the 1st 30 secs after delivery.TrueTrue or False. The composition of human milk varies with the stage of lactation.TrueTrue or False. A prophylactic injection of Vitamin K (AquaMEPHYTON) is given to prevent hemorrhage.TrueTrue or False. Colostrum is a yellowish or creamy appearing fluid that is thicker than the mature milk and contains more protein, fat-soluble vitamins, and minerals.TrueTrue or False. Dry cord care is recommended. Do not apply any substance onto the cord.TrueTrue or False. The nurse implements measurements to prevent heat loss, such as keeping the newborn away from cool surfaces or instruments.TrueTrue or False. If a newborn's amniotic fluid was meconium stained, do not stimulate an infant to breathe by rubbing the back or administering air or oxygen under pressure.TrueTrue or False. Immediately after the delivery the nurse positions the newborn on his or her side to facilitate drainage of mucus.TrueTrue or False. Breast-feeding should begin as soon after birth as possible.TrueTrue or False. The newborns respiration maybe irregular yet still be normal.TrueTrue or False. Non-immediate or appropriately-timed cord clamping is being done 10-13 minutes, approximately when the cord's pulse had stopped.TrueWhich of the following NB reflexes helps the baby to find the breast or bottle to begin feeding? a.rooting b.tonic neck c.moro d.extrusionrootingTrue or False. Acrocyanosis is a normal phenomenon in the first 24-48 hrs. after birth. However, central cyanosis is always a concern.TrueWhich statement does not pertain to the NB gastrointestinal tract? a.Accumulation of bacteria in the GIT is necessary for digestion and Vitamin K synthesis. b.First stool usually passed within 24 hours. c.Bacterial source may be airborne sources and may come from vaginal secretions during birth, hospital bedding, and from contact at the breast. d.Regurgitates easily because of poor peristaltic movement. e.Sterile at birth, but bacteria may be cultured from intestinal tract in most babies within 5 hours after birth and from all babies at 24 hours of life.Regurgitates easily because of poor peristaltic movement.Chest circumference in a term NB is ____.about 2cm less than the head circumferenceWhich is given to a NB since most are born with lower than normal level of Vit. K?AquaMEPHYTONNewborns' temperature is 37.2 C at birth and falls immediately to below normal because of ____.heat loss and immature temperature regulating mechanismsFirst measurement of weight also establishes a baseline and helps determine maturity.TrueWhich of the following assessment findings of the ears is/are not normal?Low set earsWhich statement does not pertain to the NB senses? a.Newborns vision focus best on red and green objects. b.NB demonstrate a sense of touch by quieting at a smoothing touch. c.Hearing is functional even before birth but a NB has difficulty of locating the sound. d.Newborns demonstrate they can see by blinking at a strong light or by following a bright light or toy a short distance with their eyes as soon as they are born.Newborns vision focus best on red and green objects.On physical examination to a NB, assess for pallor; cyanosis; plethora, and jaundice associated with _____.elevated bilirubinNewborns are born with active immunity. a.False b.TrueFalseWhich of the following factors during conception does not influence the weight of the newborn? a.type of delivery b.intrauterine c.racial d.genetic e.nutritionaltype of deliveryThe depth, rate and rhythm of respirations are irregular and short periods of apnea with cyanosis are normal. a.True b.FalseFalseWhich of the following birthmarks that appear slate-gray patches across the sacrum or buttocks and possibly on the arms and legs? a.Mongolian spots b.Nevus flammeus hemangiomas c.Strawberry hemangiomas d.Cavernous hemangiomasMongolian spotsWhich is used to assess the degree of respiratory distress in neonates? a.APGAR scoring b.Silverman-Andersen Index c.Ballard scoreSilverman-Andersen IndexHead circumference greater than 37 cm or less than 33 cm should be further assessed for the following, except: a.large for gestational age b.head contour c.small for gestational age d.neurologic involvement e.anencephalyhead contourWhich of the following Apgar scores indicate that the baby likely requires medical intervention? a.5 - 8 b.4 - 7 c.4 - 6 d.7 - 84 - 6Which statement does not pertain to Ballard score? a.It can be used up to 4 days after birth but in practice, the Ballard score is usually used in the first 24 hours. b.Based on gestational age, neonates are classified as early term with 37 0/7 weeks through 38 6/7 weeks. c.It is based on the neonate's physical and neuromuscular maturity. d.It allows clinicians to determine the mother's health status.It allows clinicians to determine the mother's health status.Which assessment finding pertains to a localized softening of the cranial bones caused by pressure of the fetal skull against mother's pelvic bone? a.Cephalhematoma b.Craniotabes c.Molding d.Caput succedaneumCraniotabesTrue or False. The 5-minute APGAR score tells the health care provider how well the baby tolerated the birthing process.FalseA synthetic form of the hormone produced by hypothalamus and stored in the posterior pituitary. An oxytoxic, it stimulates the uterus to contract to control postpartum hemorrhage. a.Oxytocin b.AcetaminophenOxytocinApplying an ice or cold pack to the perineum during the first 24 hours increases perineal edema and the possibility of hematoma formation, thereby increasing pain and delaying healing and comfort. a.True b.FalseFalseAs part of the episiotomy care, this should be applied in the first 24 hours after birth. a.Ice Pack b.Hot PackIce PackBefore examination of the abdomen, the woman should void a.True b.FalseTrueBlood pressure should be taken first prior to administering oxytocin. a.True b.FalseTrueCold applications between feedings and heat just before feedings may help to reduce discomfort and engorgement. a.False b.TrueTrueCool sitz baths have gained popularity because they are effective in reducing perineal edema and reducing the response of nerve endings which cause perineal discomfort. In administering a cold sitz bath, have the woman start with the water at room temperature and add ice according to the woman's comfort. a.True b.FalseTrueDocusate Sodium (Colace, Surfak) prevents the occurence of this condition. a.Diarrhea b.ConstipationConstipationDuring the first hour after the child birth, what is the interval in monitoring the uterine status a.every 15 minutes b.every 30 minutesevery 15 minutesHow many times shoul a sitz bath be used by a postpartum mother that is included in your health teaching? a.Five times a day for a maximum of 20 minutes each time b.Three to four times a day for a maximum of 20 minutes each timeThree to four times a day for a maximum of 20 minutes each timeIf an episiotomy is done at the time of birth, an icepack is generally applied to the perineum to reduce edema & provide numbing of the tissues, which promotes comfort. In some agencies, chemical ice bags are used: these are usually activated by folding both ends toward the middle. a.False b.TrueTrueMany nursing interventions are available for the relief of perineal discomfort. Before selecting a method, the nurse needs to assess the perineum to determine the degree of edema and other problems. a.True b.FalseTrueOxytocin can increase the blood pressure of a postpartum mother. If the blood pressure is >140/90 mmHg, this medication can still be given. a.True b.FalseFalseSevere edema can interfere with episiotomy healing. a.False b.TrueTrueThe mother should not used soap on her breast. Teach a woman to wash her breasts daily with clear water at the time of her bath or shower and then dry them with a soft towel. a.False b.TrueTrueThe postpartum mother underwent episiorrhaphy, usually how many days will the suture dissolve? a.10 days b.5 days10 daysThe warmth of the water in the sitz bath provides comfort, decreases pain, and promotes circulation to the tissues, which promotes circulation to the tissues, which promotes healing and reduces the incidence of infection. a.True b.FalseTrueThis can worsen the trauma and pain because it is likely to cause engorgement as less milk is removed. a.Breastfeeding b.Feeding formulaFeeding formulaThis refers to the condition when the breast and areola are very tense and distended, the mother can pump her breast to get the milk flow started and soften the areola. a.Breast engorgement b.Breastmilk productionBreast engorgementWhat type of postpartum exercise is this when in the supine or erect position, the woman inhales slowly and then exhale slowly while contacting her abdominal muscles? After a count of 10, she relaxes the muscles. a.Pelvic tilt b.Abdominal tighteningAbdominal tightening