MATERNAL TEST QUESTIONS PART 2 a.

an increased pulse rate, decreased

respiratory rate, and increased blood pressure.
1. Nurse Julia is aware that Labor is divided into
b. a decreased pulse rate, increased respiratory
how many stages?
rate, and increased blood pressure.
a. Five
c. a decreased pulse rate, decreased respiratory
b. Three
rate, and increased blood pressure.
c. Two
d. an increased pulse rate, increased respiratory
d. Four
rate, and decreased blood pressure.
2. Pen, a nurse-midwife determines that a client is
6. To promote comfort during labor, Nurse
in the second stage of labor and may start pushing.
Michelle advises a client to assume certain
What marks the beginning of the second stage, and
positions and avoid others. Which position may
what marks the end?
cause maternal hypotension and fetal hypoxia?
a. Cervical dilation of 7 to 8 cm; complete
a. Lateral position
cervical dilation
b. Squatting position
b. Complete cervical dilation; delivery of the
c. Supine position
neonate
d. Standing position
c. Cervical dilation of 7 to 8 cm; delivery of the
placenta 7. After delivering a neonate, a client delivers
d. Complete cervical dilation; delivery of the the placenta. At this time, where does nurse
placenta Adam expect to palpate the uterine fundus?
a. At the midline, 0.4″ to 0.8″ (1 to 2 cm)
3. Jannah, who is in labor receives epidural
above the umbilicus
anesthesia. The nurse should assess carefully for
b. At the midline, 0.4″ to 0.8″ (1 to 2 cm)
which adverse reaction to the anesthetic agent?
below the umbilicus
a. Hypotensive crisis
c. Left of the midline, 0.8″ to 1″ (2 to 3 cm)
b. Fetal tachycardia
above the umbilicus
c. Renal toxicity
d. Left of the midline, 0.8″ to 1″ (2 to 3 cm)
d. Increased beat-to-beat variability in the fetal
below the umbilicus
heart rate (FHR)
8. During the active phase of the first stage of
4. Nurse Venice is aware that one of the
labor, Maricris undergoes an amniotomy. After
following is the most serious adverse effect
this procedure, which nursing diagnosis takes the
associated with oxytocin (Pitocin) administration
highest priority?
during labor?
a. Deficient knowledge related to amniotomy
a. Tetanic contractions
b. Ineffective fetal cerebral tissue perfusion
b. Elevated blood pressure
related to cord compression
c. Early decelerations of fetal heart rate
c. Pain related to increasing strength of
d. Water intoxication
contractions
5. Nurse Olive asseses a client for evidence of d. Risk for infection related to rupture of
postpartum hemorrhage during the third stage of membranes
labor. Early signs of this postpartum complication
include:
9. A client with active genital herpes is admitted position.
to the labor and delivery area during the first stage d. Pushing at this time may cause rupture of
of labor. Which type of birth should nurse Roy the membranes.
anticipate for this client?
13. An assisted birth using forceps or a vacuum
a. Mid forceps
extractor may be performed for ineffective
b. Low forceps
pushing, for large infants, to shorten the second
c. Induction
stage of labor, or for a malpresentation. Nurse
d. Cesarean
Sally is caring for the mother following an
10. After a client enters the second stage of labor, assisted birth should keep which of the following
nurse Blessy notes that her amniotic fluid is port- in mind?
wine colored. What does this finding suggest? a. A vacuum extractor is safer than forceps
a. Increased bloody show because it causes less trauma to the baby and the
b. Normal amniotic fluid mother’s perineum.
c. Abruptio placentae b. The baby will develop a cephalohematoma
d. Meconium as a result of the instrumentation.
c. The use of instruments during the birth
11. Clariz arrives at the health care facility,
process is a fairly rare occurrence.
stating that her bed linens were wet when she woke
d. Additional nursing interventions are needed
up this morning. She says no fluid is leaking but
to ensure an uncomplicated postpartum.
complains of mild abdominal cramps and lower
back discomfort. Vaginal examination reveals 14. Nurse Divina is aware that the following
cervical dilation of 3 cm, 100% effacement, and would be an inappropriate indication of placental
positive ferning. Based on these findings, the nurse detachment?
concludes that the client is in which phase of the a. An abrupt lengthening of the cord
first stage of labor? b. An increase in the number of contractions
a. Active phase c. Relaxation of the uterus
b. Latent phase d. Increased vaginal bleeding
c.
15. When reviewing a fetal monitor strip, nurse
Roy looks for reassuring and nonreassuring fetal
heart rate (FHR) patterns. Which pattern is
Expulsive phase
nonreassuring?
d. Transitional phase
a. FHR that accelerates to baseline tachycardia
12. A client in labor tells April that she feels a b. Baseline FHR that doesn’t increase
strong urge to push. Physical examination reveals c. Variable FHR pattern that begins and ends
that her cervix is not completely dilated. The nurse- abruptly
midwife tells her not to push yet. What is the d. Short-term variability that doesn’t decrease
rationale for this instruction?
16. Nurse Adrian is aware that an expected
a. Early pushing may cause edema and impede
fetal adverse reaction to meperidine (Demerol)
fetal descent.
during labor is:
b. The nurse-midwife isn’t ready to assist her.
a. decreased beat-to-beat variability.
c. The fetus hasn’t rotated into the proper
b. bradycardia. education classes. Her husband, who
c. late decelerations. accompanies her, is also unprepared for
d. none known childbirth. Which nursing intervention would be
most effective for the couple at this time?
17. During labor, Amy greatly relies on her
a. Teach the client progressive muscle
husband for support. They previously attended
relaxation.
childbirth education classes, and now he’s working
b. Instruct the husband on touch, massage, and
with her on comfort measures. Which nursing
breathing patterns.
diagnosis would be appropriate for this couple?
c. Use hypnosis on the client and her husband.
a. Ineffective family coping: Compromised
d. Teach the client and her husband about pain
related to labor
transmission.
b. Readiness for enhanced family coping related
to participation in pregnancy and delivery 21. Which of the following physiologic
c. Powerlessness related to pain changes during labor makes it necessary for
d. Ineffective role performance related to nurse Hazel to assess blood pressure frequently?
involvement with the pregnancy a. Blood pressure decreases as a sign of
maternal pain.
18. Late in the first stage of labor, Olivia receives
b. Alterations in cardiovascular function affect
a spinal block to relieve discomfort. A short time
the fetus
later, her husband tells the nurse that his wife feels
c. Blood pressure decreases at the peak of each
dizzy and is complaining of numbness around her
contraction.
lips. What do the client’s symptoms suggest?
d. Decreased blood pressure is the first sign of
a. Anesthesia overdose
preeclampsia.
b. Transition to the second stage of labor
c. Anxiety 22. During the fourth stage of labor, Jessica
d. Dehydration should be assessed carefully for:
a. uterine atony
19. Denice with intrauterine growth retardation is
b. complete cervical dilation
admitted to the labor and delivery unit and started
c. placental expulsion
on an I.V. infusion of oxytocin (Pitocin). Which of
d. umbilical cord prolapse
the following is least likely to be included in her
plan of care? 23. Several minutes after a vaginal delivery,
a. Carefully titrating the oxytocin based on her nursing assessment reveals blood gushing from
pattern of labor the client’s vagina, umbilical cord lengthening,
b. Monitoring vital signs, including assessment of and a globular-shaped uterus. Nurse Luz should
fetal well-being, every 15 to 30 minutes suspect which condition?
c. Allowing the client to ambulate as tolerated a. Cervical or vaginal laceration
d. Helping the client use breathing exercises to b. Placental separation
manage her contractions c. Postpartum hemorrhage
d. Uterine involution
20. Lou is in the first stage of labor enters the
labor and delivery area. She seems anxious and 24. Nurse Mariane is caring for a client who’s
tells the nurse that she hasn’t attended childbirth in labor. The physician still isn’t present. After
the baby’s head is delivered, which nursing
intervention would be most appropriate?
a. Checking for the umbilical cord around the
baby’s neck\
b. Placing antibiotic ointment in the baby’s eyes
c. Turning the baby’s head to the side to drain
secretions
d. Assessing the baby for respirations
25. Vicky, who is in labor shouts to the nurse,
“My baby is coming right now! I feel like I have to
push!” An immediate nursing assessment reveals
that the head of the fetus is crowning. After asking
another staff member to notify the physician and
setting up for delivery, which nursing intervention
is most appropriate?
a. Gently pulling at the baby’s head as it’s
delivered
b. Holding the baby’s head back until the
physician arrives
c. Applying gentle pressure to the baby’s head as
it’s delivered
d. Placing the mother in the Trendelenburg
position until the physician arrives
ANSWERS AND RATIONALE: cava by the fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and,
1. Answer D. Labor is divided into four stages: ultimately, fetal hypoxia. The other positions
first stage, onset of labor to full dilation; second promote comfort and aid labor progress. For
stage, full dilation to birth of the baby; third stage, instance, the lateral, or side-lying, position
birth of the placenta; and fourth stage, 1-hour improves maternal and fetal circulation,
postpartum. The first stage is divided into three enhances comfort, increases maternal relaxation,
phases: early, active, and transition. reduces muscle tension, and eliminates pressure
2. Answer B. The second stage of labor begins points. The squatting position promotes comfort
with complete cervical dilation and ends with by taking advantage of gravity. The standing
delivery of the neonate. position also takes advantage of gravity and
aligns the fetus with the pelvic angle.
3. Answer A. Hypotensive crisis may occur after
epidural anesthesia administration as the anesthetic 7. Answer B. After delivery of the placenta, the
agent spreads through the spinal canal, blocking fundus is normally firmly contracted at the
sympathetic innervation. Other signs and symptoms midline, 0.4" to 0.8" (1 to 2 cm) below the
of hypotensive crisis associated with epidural umbilicus.
anesthesia may include fetal bradycardia (not 8. Answer B. Amniotomy increases the risk of
tachycardia) and decreased (not increased) beat-to- cord prolapse. If the prolapsed cord is
beat variability in the FHR. Urine retention, not compressed by the presenting fetal part, the fetal
renal toxicity, may occur during the postpartum blood supply may be impaired, jeopardizing the
period. fetal oxygen supply. Because lack of oxygen to
4. Answer A. Tetanic contractions are the most the fetus may cause fetal death, the nursing
serious adverse effect associated with diagnosis of Ineffective fetal cerebral tissue
administering oxytocin. When tetanic contractions perfusion takes priority over diagnoses of
occur, the fetus is at high risk for hypoxia and the Deficient knowledge, Pain, and Risk for
mother is at risk for uterine rupture. The client may infection.
be at risk for pulmonary edema if large amounts of 9. Answer D. For a client with active genital
oxytocin have been administered, and this drug can herpes, cesarean birth helps avoid infection
also increase blood pressure. However, pulmonary transmission to the neonate, which would occur
edema and increased blood pressure aren’t the most during a vaginal birth. Mid forceps and low
serious adverse effects. Early decelerations of fetal forceps are types of vaginal births that could
heart rate aren’t associated with oxytocin transmit the herpes infection to the neonate.
administration. Induction is used only during vaginal birth;
5. Answer D. An increased pulse rate followed by therefore, it’s inappropriate for this client.
an increased respiratory rate and decreased blood 10. Answer C. Port-wine-colored amniotic
pressure may be the first signs of postpartum fluid isn’t normal and may indicate abruptio
hemorrhage and hypovolemic shock. placentae. Increased bloody show is a normal
6. Answer C. The supine position causes finding and causes light pink amniotic fluid.
compression of the client’s aorta and inferior vena Meconium turns amniotic fluid green
11. Answer B. The latent phase of the first stage attempts to compensate for a growing oxygen
of labor is associated with irregular, short, mild deficit. A reassuring variable pattern has an
contractions; cervical dilation of 3 to 4 cm; and abrupt onset and end. The baseline FHR doesn’t
abdominal cramps or lower back discomfort. increase and short-term variability doesn’t
During the active phase, the cervix dilates to 7 cm decrease.
and moderately intense contractions of 40 to 50
16. Answer A. Possible fetal adverse reactions
seconds’ duration occur every 2 to 5 minutes. Fetal
include both moderate central nervous system
descent continues throughout the active phase and
depression and decreased beat-to-beat variability.
into the transitional phase, when the cervix dilates
Bradycardia and late decelerations don’t occur as
from 8 to 10 cm and intense contractions of 45 to
a result of meperidine administration.
60 seconds’ duration occur every 1½ to 2 minutes.
The first stage of labor doesn’t include an expulsive 17. Answer B. The client and her husband are
phase. working together for a common goal. He’s
offering support, and they’re sharing the
12. Answer A. Pushing (bearing down) before the
experience of childbirth, making Readiness for
cervix is completely dilated may cause edema and
enhanced family coping related to participation
tissue damage and may impede fetal descent.
in pregnancy and delivery an appropriate nursing
Telling the client not to push because the nurse-
diagnosis. The other options suggest that the
midwife isn’t ready to assist is inappropriate and
couple have a problem that isn’t indicated in the
unprofessional. If the cervix were completely
question.
dilated, the nurse-midwife could assist the client in
changing position to help reposition the fetus. The 18. Answer A. Dizziness, circumoral
client’s membranes should have ruptured already. numbness, and slurred speech indicate anesthesia
overdose. Transition to the second stage of labor
13. Answer A. When used properly, a vacuum
is marked by an increased urge to push, an
extractor is a safer delivery with fewer
increase in bloody show, grunting, gaping of the
complications for the mother and the baby than a
anus, involuntary defecation, thrashing about,
forceps delivery. Cephalohematomas occur more
loss of control over breathing techniques, and
often in assisted births than in unassisted births.
nausea and vomiting. Anxiety and dehydration
Instruments are used during delivery when
rarely cause dizziness or circumoral numbness.
individually necessary. No additional nursing
interventions are needed during the postpartum 19. Answer C. Because the fetus is at risk for
period. complications, frequent and close monitoring is
necessary. Therefore, the client shouldn’t be
14. Answer C. Relaxation isn’t an indication for
allowed to ambulate. Carefully titrating the
detachment of the placenta. An abrupt lengthening
oxytocin, monitoring vital signs, including fetal
of the cord, an increase in the number of
well-being, and assisting with breathing
contractions, and an increase in vaginal bleeding
exercises are appropriate actions to include.
are all indications that the placenta has detached
from the wall of the uterus. 20. Answer B. If the unprepared client has a
support person, the nurse should focus on that
15. Answer A. In a nonreassuring pattern, the
person’s supporting role, demonstrating touch,
FHR accelerates to baseline tachycardia as the fetus
massage, and simple breathing patterns. The
other options are inappropriate at this time because postpartum hemorrhage, usually caused by
they may make the client and her husband more uterine atony, the uterus isn’t globular. Uterine
anxious. involution can’t begin until the placenta has been
delivered.
21. Answer B. During contractions, blood
pressure increases and blood flow to the 24. Answer A. After the baby’s head is
intervillous spaces decreases, compromising the delivered, the nurse should check for the cord
fetal blood supply. Therefore, the nurse should around the baby’s neck. If the cord is around the
frequently assess the client’s blood pressure to neck, it should be gently lifted over the baby’s
determine whether it returns to precontraction head. Antibiotic ointment is administered to the
levels and allows adequate fetal blood flow. During baby after birth, not during delivery of the head,
pain and contractions, the maternal blood pressure to prevent gonorrheal conjunctivitis. The baby’s
usually increases, rather than decreases. head isn’t turned during delivery. After delivery,
Preeclampsia causes the blood pressure to increase the baby is held with the head lowered to help
— not decrease. with drainage of secretions. If a bulb syringe is
available, it can be used to gently suction the
22. Answer A. Uterine atony should be carefully
baby’s mouth. Assessing the baby’s respiratory
assessed during the fourth stage. The second stage
status should be done immediately after delivery.
of labor begins with complete cervical dilation and
ends with birth. The third stage begins immediately 25. Answer C. Gentle pressure applied to the
after birth and ends with the separation and baby’s head as it’s delivered prevents rapid
expulsion of the placenta. Immediately after expulsion, which can cause brain damage to the
delivery, the placenta is evaluated carefully for baby and perineal tearing in the mother. Never
completeness, and the client is assessed for pull at the baby’s head or hold the head back.
excessive bleeding or a relaxed uterus. Umbilical Placing the mother in the Trendelenburg position
cord prolapse, displacement of the umbilical cord won’t halt labor and may cause respiratory
to a position at or below the fetus’s presenting part, difficulties.
occurs most commonly when amniotic membranes
rupture before fetal descent. The client should be
assessed for a visible or palpable umbilical cord in
the birth canal, violent fetal activity, or fetal
bradycardia with variable deceleration during
contractions. The presence of umbilical cord
prolapse requires an emergency delivery.
23. Answer B. Placental separation is
characterized by a sudden gush or trickle of blood
from the vagina, further protrusion of the umbilical
cord from the vagina, a globular-shaped uterus, and
an increase in fundal height. With cervical or
vaginal laceration, the nurse notes a consistent flow
of bright red blood from the vagina. With