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MCN - Midterm Exam Review

Terms in this set (159)

What is the intensity of uterine contractions if the fundus is firm and difficult to indent by pressing the fingertips?
moderate
Which pertains to a measure of the degree of fetal descent of the presenting part of the fetus through the birth canal?
station
Engagement confirms the adequacy of the pelvic inlet, midpelvis, and outlet.
False
Which theory suggests that labor begins when progesterone level in the body decreases?
progesterone deprivation
Which phase of the uterine contraction is used in assessing the intensity?
peak
What is the widest anteroposterior diameter of the fetal skull?
occipitomental
What is the presenting part of the fetus in a vertex type of cephalic presentation?
occiput
Asynclitism occurs when the sagittal suture is midway between the symphysis pubis and sacral promontory.
False
Which hormone is released when there is pressure on the cervix by the presenting part of the baby?
Oxytocin
In poor flexion, the fetal attitude allows the face to present in the pelvis.
False
What is the smallest anteroposterior diameter of the fetal skull?
suboccipitobregmatic
Which is considered as the normal fetal attitude in cephalic presentation?
Complete Flexion
The movement of the passenger through the birth canal is determined by several interacting factors namely, the fetal head, attitude, lie, presentation and position.
True
Which factor affecting labor and birth process composed of rigid bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and introitus?
Passage
Which fetal position is considered as the most common?
LOA
What is known as the largest part of the fetus?
Head
Secondary power is used by the woman during the first stage of labor for an effective cervical dilatation and effacement.
False
The upper portion of the uterus is passive and the lower uterine segment becomes active during uterine contractions.
False
What causes the effacement and dilatation of the cervix and descent of the fetus?
primary power
What hormone is responsible for the softening of cartilage in the pelvis during labor & delivery?
Relaxin
Approximately 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.
True
Which 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 cervix
b. Intervals between contractions gradually shorten
Approximately how many lbs is loss during labor and delivery of a mother?
1-3 lbs
What danger might occur if amniotic membranes rupture while engagement has not yet occured?
prolapse cord
The best position for a woman in labor.
lateral
What food can you offer to a woman in labor?
sips of fluid or ice cubes or hard candy for fast fluid and calorie absorption
Amniotic membranes, once labor is well established can be ruptured through:
amniotomy
In primiparas, lightening or descent of the fetal presenting part into the pelvis occurs approximately how many week/s before term?
2 weeks
If 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.
True
The sudden burst of energy of the mother is physiologically related to:
increase epinephrine which is caused by decreased in progesterone
Mother'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 bladder
The surest sign that labor has begun is progressive uterine contractions.
True
Signs of true labor do not involve uterine and cervical changes.
False
The client's BP commonly increases during what stages of labor because of the contractions?
first and second stages
Throughout pregnancy, the cervix feels softer than normal, similar to the consistency of an earlobe. What do you call this sign?
Goodell's sign
Lightening probably occurs early in primiparas because of tight abdominal muscles.
true
True labor contractions are usually felt in the abdomen or inguinal region.
false
Bloody show is considered a sign that labor will begin within 24 - 48 hrs.
true
A 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 vagina
Lengthening of the umbilical cord
A 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 massage
Showering if not contraindicated
A 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 contraindicated
c.Sacral counterpressure
A 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 firm
Massage the fundus until it is firm
After 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.True
True
Cervical dilatation during the latent phase of the first stage of labor.
0-3cm
During 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 lochia
It is believed that tranquilizers increase the level of anxiety of a woman.
False
Multigravida 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.
True
Passage 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. BACDEF
BACDEF
The first stage of labor is also known as the stage of dilatation.
True
This refers to the amount of pain one is willing to endure.
Pain Tolerance
This refers to the injection of an anesthetic agent into the intracutaneous, subcutaneous, and intramuscular areas of the perineum.
Local Infiltration Anesthesia
When 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 contractions
between uterine contractions
To 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 choices
peak of the uterine contraction
What 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 abdomen
Uterus becomes firm and globular in shape
When 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 institution
1 to 2 hours depending on the policy of the institution
Which client's manifestation upon admission that a vaginal examination must be done immediately?
a.an interval of 4 mins
b.+1 station
c.an urge to bear down
d.frequency of contractions is 4-5 mins
an urge to bear down
Which position during labor increases the pelvic diameter?
a.sitting
b.standing
c.side lying
d.hands and knees
sitting
If 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 mins
6 mins
If 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 syndrome
blood incompatibility
If 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 administration
pant-blow breathing
What 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 cord
controlled cord traction with counter traction
Which 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.True
True
For 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.station
b. cardinal movements
Which drug is administered to the mother 1 min. after the delivery of the baby?
a.methergine
b.carboprost
c.cytotec
d.oxytocin
d.oxytocin
Which allows the delivery of the fetal head in a vertex presentation?
a.flexion
b.expulsion
c.extension
d.external rotation
extension
Which of the following controls the rate at which the head is born and prevents laceration?
a.McRoberts maneuver
b.Ritgen's maneuver
c.Fundal pressure
Ritgen's maneuver
The 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 mins
30 mins
Which 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 massage
fundal massage
The 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.False
True
When 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 birth
b.1-3 mins after birth
True 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.
True
True or False. The second day after birth is potentially the most dangerous time for a woman.
False
True 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.
False
True or False. Many mothers may feel abandoned and less important after giving birth than they did during pregnancy or labor.
True
True or False. Pregnancy hormones begin to increase as soon as the placenta is no longer present.
False
True or False. The postpartum period is a time of transition during which a couple gives up concepts such as "childless" or "parents of one".
True
True or False. The postpartum period is a time of transition during which a couple gives up concepts such as "childless" or "parents of one".
False
True or False. In LETTING GO PHASE, the woman begins to take a stronger interest in her infant and begins maternal role behaviors.
False
True or False. Mothers in TAKING HOLD PHASE gave up their ideal birth experience and reconcile it with what really occurred.
False
True or False. TAKING IN PHASE's primary focus is on recovery from birth and her need for food, fluids and deep restorative sleep.
True
True or False. A well-contracted fundus feels so firm it can be compared with a grapefruit in both size and tenseness.
True
True or False. Maternal role attainment is the process by which a woman learns mothering behaviors and becomes comfortable with her identity as a mother.
True
True or False. The uterus of a breastfeeding mother may contract even more quickly, because progesterone, which is released with breastfeeding, stimulates uterine contractions.
False
True or False. Digestion and absorption begin to be active again soon after birth unless a woman has had a cesarean delivery.
True
True or False. Extensive diaphoresis and diuresis begin almost immediately after birth to rid the body of this fluid.
True
True or False. TAKING IN PHASE is the time when the new parents review their pregnancy and the labor and birth.
True
True or False. The Formal Stage of Maternal Goal Attainment begins when the mother begins to make her own choices about mothering.
False
True or False. Usual blood loss with a vaginal birth is 1,300 to 1,500 ml.
False
True or False. Anticipatory guidance and individualized support from health care personnel are important to help the parents understand that this response is normal.
True
True or False. In the third phase, called TAKING IN, a woman finally redefines her new role.
False
True or False. Nurses help prevent engorgement by assisting women to begin breastfeeding early and to feed frequently.
True
True or False. At the time fo delivery and the baby is crying and breathing normally, we avoid any manipulation, such as routine suctioning.
True
True or False. At the time of delivery and the baby is crying and breathing normally, we avoid any manipulation, such as routine suctioning.
True
True or False. The instillation of eye prophylaxis may be delayed up to 1hour after birth to allow eye contact during parent newborn bonding.
True
True 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.
True
True or False. Normal temperature of a newborn is 36.4 to 37.2 degree celsius.
True
True or False. Bathing should be delayed until 24 hours after birth.
True
True 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.
True
True 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.
True
True or False. Calling out of the time of birth is being done within the 1st 30 secs after delivery.
True
True or False. The composition of human milk varies with the stage of lactation.
True
True or False. A prophylactic injection of Vitamin K (AquaMEPHYTON) is given to prevent hemorrhage.
True
True 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.
True
True or False. Dry cord care is recommended. Do not apply any substance onto the cord.
True
True or False. The nurse implements measurements to prevent heat loss, such as keeping the newborn away from cool surfaces or instruments.
True
True 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.
True
True or False. Immediately after the delivery the nurse positions the newborn on his or her side to facilitate drainage of mucus.
True
True or False. Breast-feeding should begin as soon after birth as possible.
True
True or False. The newborns respiration maybe irregular yet still be normal.
True
True or False. Non-immediate or appropriately-timed cord clamping is being done 10-13 minutes, approximately when the cord's pulse had stopped.
True
Which 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.extrusion
rooting
True or False. Acrocyanosis is a normal phenomenon in the first 24-48 hrs. after birth. However, central cyanosis is always a concern.
True
Which 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 circumference
Which is given to a NB since most are born with lower than normal level of Vit. K?
AquaMEPHYTON
Newborns' temperature is 37.2 C at birth and falls immediately to below normal because of ____.
heat loss and immature temperature regulating mechanisms
First measurement of weight also establishes a baseline and helps determine maturity.
True
Which of the following assessment findings of the ears is/are not normal?
Low set ears
Which 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 bilirubin
Newborns are born with active immunity.
a.False
b.True
False
Which 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.nutritional
type of delivery
The depth, rate and rhythm of respirations are irregular and short periods of apnea with cyanosis are normal.
a.True
b.False
False
Which 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 hemangiomas
Mongolian spots
Which is used to assess the degree of respiratory distress in neonates?
a.APGAR scoring
b.Silverman-Andersen Index
c.Ballard score
Silverman-Andersen Index
Head 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.anencephaly
head contour
Which of the following Apgar scores indicate that the baby likely requires medical intervention?
a.5 - 8
b.4 - 7
c.4 - 6
d.7 - 8
4 - 6
Which 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 succedaneum
Craniotabes
True or False. The 5-minute APGAR score tells the health care provider how well the baby tolerated the birthing process.
False
A 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.Acetaminophen
Oxytocin
Applying 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.False
False
As part of the episiotomy care, this should be applied in the first 24 hours after birth.
a.Ice Pack
b.Hot Pack
Ice Pack
Before examination of the abdomen, the woman should void
a.True
b.False
True
Blood pressure should be taken first prior to administering oxytocin.
a.True
b.False
True
Cold applications between feedings and heat just before feedings may help to reduce discomfort and engorgement.
a.False
b.True
True
Cool 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.False
True
Docusate Sodium (Colace, Surfak) prevents the occurence of this condition.
a.Diarrhea
b.Constipation
Constipation
During the first hour after the child birth, what is the interval in monitoring the uterine status
a.every 15 minutes
b.every 30 minutes
every 15 minutes
How 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 time
Three to four times a day for a maximum of 20 minutes each time
If 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.True
True
Many 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.False
True
Oxytocin 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.False
False
Severe edema can interfere with episiotomy healing.
a.False
b.True
True
The 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.True
True
The postpartum mother underwent episiorrhaphy, usually how many days will the suture dissolve?
a.10 days
b.5 days
10 days
The 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.False
True
This can worsen the trauma and pain because it is likely to cause engorgement as less milk is removed.
a.Breastfeeding
b.Feeding formula
Feeding formula
This 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 production
Breast engorgement
What 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 tightening
Abdominal tightening
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