Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8t, Exams of Health sciences

Download Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8t and more Exams Health sciences in PDF only on Docsity! Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 A nurse is teaching a classroom of teenage girls about the female reproductive system. After teaching, the nurse asks the students to describe the release of an ovum during ovulation. Which student’s response suggests she correctly understood the nurse’s teaching? 1. “During ovulation, an egg is released from the ovary and enters the fallopian tube.” 2. “Around the middle of the menstrual cycle, one of the fallopian tubes releases an egg.” 3. “Ovulation is when the uterus releases an unfertilized egg or ovum.” 4. “The endometrium is where the eggs are formed and released into the fallopian tube.” Correct Answer: 1 Rationale 1: The egg is formed in the ovary and once released, it enters the fallopian tube. Rationale 2: The egg is formed in the ovary and then released near the fimbria of the fallopian tube. Rationale 3: The egg is formed in the ovary and travels by way of the fallopian tube to the uterus. Rationale 4: The uterine endometrium is the site of implantation of a fertilized egg. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO01 – Identify the structures and functions of the female reproductive system. Question 2 Type: MCSA The clinic nurse is caring for a young woman seeking contraception because she has recently married and become sexually active. The teen states, “The opening of my husband’s penis isn’t at the tip; it’s around the corner below the tip. He tells me that he was born that way. Will that cause problems if we want to have children?” What is the best response for the nurse to give? “This variation is called: 1. “Epispadias. It is not likely to impact his fertility.” 2. “Epispadias. It will likely cause him to be infertile.” 3. “Hypospadias. It is not likely to impact his fertility.” 4. “Hypospadias. It will likely cause him to be infertile.” Correct Answer: 3 Rationale 1: Epispadias is the condition where the urethral opening is on the upper aspect of the penis. The patient is describing hypospadias, when the urethral opening is on the lower side of the penis. Mild hypospadias, when the urethral opening is on the glans of the penis, does not impact fertility. Rationale 2: Epispadias is the condition where the urethral opening is on the upper aspect of the penis. The patient is describing hypospadias, when the urethral opening is on the lower side of the penis. Mild hypospadias, when the urethral opening is on the glans of the penis, does not impact fertility. Rationale 3: The patient is describing hypospadias, which is the urethral opening on the lower aspect of the penis. Mild hypospadias, when the urethral opening is on the glans of the penis, does not impact fertility. Rationale 4: The patient is describing hypospadias, where the urethral opening is on the lower side of the penis. Mild hypospadias, where the urethral opening is on the glans of the penis, does not impact fertility. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Question 5 Type: MCSA A pregnant adolescent asks the nurse, “Why does the physician call measuring my uterus a ‘fundal height’?” The nurse’s answer is based on the fact that the fundus of the uterus is located: 1. In the elongated portion where the fallopian tubes enter. 2. In the lower third area. 3. At the uppermost (dome-shaped top) portion. 4. Between the internal cervical os and the endometrial cavity. Correct Answer: 3 Rationale 1: The elongated portion where the fallopian tubes enter the uterus is called the cornua. Rationale 2: The lower third of the uterus is called the cervix or neck. Rationale 3: The rounded, uppermost (dome-shaped top) portion of the uterus that extends above the points of attachment of the fallopian tubes is called the fundus. Rationale 4: The isthmus is the portion of the uterus between the internal cervical os and the endometrial cavity. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 – Explain the significance of specific female reproductive structures during childbirth. Question 6 Type: MCSA A nurse teaches newly pregnant patients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is: 1. Estrogen. 2. Human chorionic gonadotropin (hCG). 3. Progesterone. 4. Luteinizing hormone. Correct Answer: 2 Rationale 1: Estrogen is an ovarian hormone. Rationale 2: When the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete human chorionic gonadotropin (hCG) hormone to maintain the corpus luteum. Rationale 3: Progesterone is an ovarian hormone. Rationale 4: Luteinizing hormone is excreted by the anterior pituitary. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 – Summarize the actions of the hormones that affect reproductive functioning. Question 7 Type: MCSA A school nurse is teaching a health class to middle school children. The nurse explains that follicle-stimulating hormone (FSH) and luteinizing hormone (LH) Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 are secreted by the: 1. Hypothalamus. 2. Ovaries and testes. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 3. Posterior pituitary. 4. Anterior pituitary. Correct Answer: 4 Rationale 1: The hypothalamus secretes gonadotropin-releasing hormone to the pituitary gland in response to signals from the central nervous system. Rationale 2: The ovaries secrete the female hormones estrogen and progesterone, and the testes secrete testosterone. Rationale 3: The posterior pituitary gland secretes oxytocin and anti-diuretic hormone. Rationale 4: The anterior pituitary secretes FSH and LH, which are primarily responsible for maturation of the ovarian follicle. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 – Summarize the actions of the hormones that affect reproductive functioning. Question 8 Type: MCSA The nurse is presenting a community education session on female hormones. Which statement from a participant indicates the need for further information? 1. “Estrogen is what causes females to look female.” 2. “The presence of some hormones causes other to be secreted.” 3. “Progesterone is present at the end of the menstrual cycle.” 4. “Prostaglandin is responsible for achieving conception.” Correct Answer: 4 Rationale 1: This is a true statement. The question is asking for an incorrect statement. Estrogen causes secondary sex characteristics, such as enlarged breasts and widened hips. Rationale 2: This is a true statement. The question is asking for an incorrect statement. One example is that the production of gonadotropin-releasing hormone (GnRH) causes the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Rationale 3: This is a true statement. The question is asking for an incorrect statement. Progesterone is present in large quantities during the secretory phase of the menstrual cycle. Rationale 4: Prostaglandin is not related to conception. Prostaglandin is called the hormone of pregnancy because it maintains pregnancy. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 – Summarize the actions of the hormones that affect reproductive functioning. Question 9 Type: MCSA A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone? 1. Estrogen 2. Progesterone Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 days. Rationale 2: For a female with a 28-day cycle, the follicular phase comprises days 1–14 of the menstrual cycle, and the luteal phase comprises days 15–28. The luteal phase does not vary. Rationale 3: The luteal phase is the second half of the cycle. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Rationale 4: The follicular phase comprises days 1–14 of the menstrual cycle, not when the egg is fertilized. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 – Identify the two phases of the ovarian cycle and the changes that occur in each phase. Question 12 Type: MCSA The nurse is preparing a handout on the ovarian cycle to a group of middle school girls. Which information should the nurse include? 1. There are two phases of the ovarian cycle: luteal and follicular. 2. Irregular menstrual cycles have varying lengths of the follicular phase. 3. The ovum travels from the ovary to the tube during the luteal phase. 4. The hormone human chorionic gonadotropin stimulates ovulation. Correct Answer: 1 Rationale 1: The two phases of the ovarian cycle are follicular (days 1–14 of the menstrual cycle) and luteal (days 15–28 of the menstrual cycle). Rationale 2: Menstrual cycles that are irregular in length have a consistent follicular phase but a varying luteal phase. Rationale 3: The ovum is released from the graafian follicle of the ovary and travels to the fallopian tube during the follicular phase of the ovarian cycle. Rationale 4: Human chorionic gonadotropin (hCG) is secreted by a fertilized ovum and does not stimulate ovulation. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 – Identify the two phases of the ovarian cycle and the changes that occur in each phase. Question 13 Type: MCSA The nurse is preparing a presentation on the menstrual cycle for a group of high school students. Which statement should the nurse include in this presentation? 1. “The menstrual cycle has five distinct phases that occur during the month.” 2. “One hormone controls the phases of the menstrual cycle.” 3. “The secretory phase occurs when a woman is most fertile.” 4. “Menstrual cycle phases vary in order from one woman to another.” Correct Answer: 3 Rationale 1: There are four phases of the menstrual cycle: menstrual, proliferative, secretory, and ischemic phases. Rationale 2: Four hormones control ovulation and therefore the menstrual cycle: progesterone, estrogen, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). Rationale 3: During the secretory phase, the endometrium is thickest, and glycogen is produced to nourish a fertilized ovum. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Rationale 4: Although the length of the menstrual cycle might vary, the phases of the menstrual cycle always occur in the same order. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 – Describe the phases of the menstrual cycle, their dominant hormones, and the changes that occur in each phase. Question 14 Type: MCSA In preparation for teaching a women’s community center class about physiologic changes during menopause, the nurse is preparing a handout for students. Which information should the nurse include in her teaching? 1. The ovaries remain small after puberty, but they increase in size following menopause. 2. Ovarian secretion of estrogen decreases between the ages of 45 to 55, after which point ovulatory activity ceases. 3. Due to changes in estrogen levels, the labia minora increase in size after menopause. 4. After menopause, the endometrium continues to undergo monthly degeneration and renewal. Correct Answer: 2 Rationale 1: The ovaries of girls are small, but they become larger after puberty and then decrease in size following menopause. Rationale 2: Between the ages of 45 and 55, a woman’s ovaries secrete decreasing amounts of estrogen. Eventually, ovulatory activity ceases and menopause occurs. Rationale 3: The labia minora decrease in size after menopause because of changes in estrogen levels. Rationale 4: From menarche to menopause, the endometrium undergoes monthly degeneration and renewal in the absence of pregnancy. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 – Summarize the actions of the hormones that affect reproductive functioning. Question 15 Type: MCSA A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0° F) for the past 36 hours. This most likely indicates that: 1. Menstruation is about to begin. 2. Ovulation will occur soon. 3. Ovulation has occurred. 4. She is pregnant and will not menstruate. Correct Answer: 3 Rationale 1: A temperature increase does not occur when menstruation is about to Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Question 2 Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Type: MCSA When taking a sexual history from a patient, the nurse should: 1. Ask questions that the patient can answer with a “yes” or “no.” 2. Ask mostly open-ended questions. 3. Have the patient fill out a comprehensive questionnaire and review it after the patient leaves. 4. Try not to make much direct eye contact. Correct Answer: 2 Rationale 1: “Yes-or-no” answers indicate closed-ended questions that will not encourage the patient to share the necessary information. Rationale 2: Open-ended questions are often useful in eliciting information because they encourage more than a one-word answer. Rationale 3: Filling out a questionnaire and reviewing it after the patient leaves is not appropriate. It should be reviewed in the presence of the patient, encouraging conversation regarding the results. Rationale 4: It is helpful to use direct eye contact as much as possible, unless culturally unacceptable. Eye contact encourages a connection between the involved parties and shows care and concern. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 – Identify appropriate nursing care based on the results of the patient’s sexual history. Question 3 Type: MCSA Which patient would the nurse document as exhibiting signs and symptoms of primary dysmenorrhea? 1. 17-year-old, has never had a menstrual cycle 2. 16-year-old, had regular menses for 4 years, but has had no menses in four months 3. 19-year-old, regular menses for 5 years that have suddenly become painful 4. 14-year-old, irregular menses for one year, experiences cramping every cycle Correct Answer: 4 Rationale 1: This is primary amenorrhea, or the lack of menses. Rationale 2: Secondary amenorrhea is the term used when a patient has had regular cycles that cease. Rationale 3: Secondary dysmenorrheal is the sudden onset of pain and discomfort with menses. Rationale 4: Primary dysmenorrhea is when menstruation has been painful from the first menstrual cycle and consistently continues to be painful each month. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO02 – Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Question 4 Type: MCSA Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Type: MCSA A patient comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for two years. The most likely cause for the patient’s complaint is: 1. Primary dysmenorrhea. 2. Secondary dysmenorrhea. 3. Menorrhagia. 4. Hypermenorrhea. Correct Answer: 2 Rationale 1: Primary dysmenorrhea is defined as cramps without underlying disease. Rationale 2: Secondary dysmenorrhea is associated with pathology of the reproductive tract and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device. Rationale 3: Menorrhagia is excessive, profuse flow. Rationale 4: Hypermenorrhea is an abnormally long menstrual flow. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 – Discriminate between the signs, symptoms, and nursing management of women with dysmenorrhea and premenstrual syndrome. Question 7 Type: MCMA Which issues should the nurse consider when counseling a patient on contraceptive methods? Standard Text: Select all that apply. 1. Cultural perspectives on menstruation and pregnancy 2. Efficacy of the method 3. Future childbearing plans 4. Whether the patient is a vegetarian 5. Age at menarche Correct Answer: 1,2,3 Rationale 1: Cultural and religious beliefs, practices, and sanctions must be considered when discussing contraception with patients in order to avoid insulting a patient for whom a particular type of contraceptive method is prohibited by her background. Rationale 2: Efficacy of contraceptive methods varies and must be considered when discussing contraception with patients. When pregnancy is medically contraindicated, high-efficacy methods (such as an IUD, hormonal methods, or sterilization) should be discussed with the patient. When the patient would like to avoid pregnancy at this time, but pregnancy is not medically contraindicated, lower-efficacy methods (such as diaphragm, cervical cap, or Today sponge) could be discussed. Rationale 3: If a patient desires children in the future, sterilization methods would be inappropriate to discuss. Rationale 4: Vegetarianism has no impact on contraceptive method use. Rationale 5: Age at menarche has no impact on contraceptive method use. Global Rationale: Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Learning Outcome: LO04 – Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today. Question 8 Type: MCSA A patient has decided to use the NuvaRing vaginal contraceptive ring as her method of contraception. Which statement suggests the patient needs further instruction? 1. “I do not need to be examined in order to determine the contraceptive ring size that is correct for me.” 2. “Every three months, I will need to remove the contraceptive ring and replace it with a new one.” 3. “When I store my replacement rings, I should keep them in my refrigerator.” 4. “The contraceptive ring provides a sustained release of low-dose contraceptive.” Correct Answer: 2 Rationale 1: One size of the NuvaRing fits virtually all women. Rationale 2: The ring is left in place for 3 weeks and then removed for 1 week to allow for withdrawal bleeding. Rationale 3: Replacement rings should be kept in the refrigerator to maintain integrity. Rationale 4: The contraceptive ring provides a low-dose, sustained- release hormonal contraceptive. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 – Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today. Question 9 Type: MCSA Which patient is not a good candidate for Depo-Provera (DMPA)? 1. One who wishes to get pregnant within three months 2. One who wishes to breastfeed 3. One with a vaginal prolapse 4. One who weighs 200 pounds Correct Answer: 1 Rationale 1: Return of fertility after the use of Depo-Provera takes an average of nine months. Rationale 2: Studies have proven there is no harm to a breastfed baby when a woman uses Depo-Provera. Rationale 3: There is no correlation between a vaginal prolapse and use of Depo- Provera. Rationale 4: There is no correlation between one’s weight and use of Depo-Provera. Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 – Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today. Question 10 Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Learning Outcome: LO05 – Delineate basic gynecologic screening procedures indicated for well women. Question 12 Type: MCSA What is the best indicator that the patient is experiencing menopause? 1. No menses for 8 consecutive months 2. Hot flashes and night sweats 3. High serum FSH with low serum estrogen 4. Diagnosed with osteoporosis 4 months ago Correct Answer: 3 Rationale 1: Menopause is defined as 12 months of amenorrhea. Rationale 2: Although hot flashes and night sweats are common in menopause, lab values or twelve months of amenorrhea are better indicators. Rationale 3: Examining serum levels of the hormones FSH and estrogen is a very accurate indication of menopause. Rationale 4: Menopause is not the only cause of osteoporosis; therefore, the diagnosis of osteoporosis 4 months ago is not an indicator of menopause. Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 – Explain the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women. Question 13 Type: MCSA A 63-year-old female patient requests information about complementary and alternative therapies that promote wellness during menopause. Which therapies should the nurse recommend? 1. Non-weight-bearing exercise, such as swimming. 2. Increased consumption of phytoestrogens (i.e., plant products with estrogen properties) for women with a history of endometeriosis or fibroids. 3. Calcium intake of 600 mg per day to help prevent osteoporosis. 4. Soy for reducing insomnia symptoms. Correct Answer: 4 Rationale 1: Weight-bearing exercises such as walking, jogging, tennis, and low- impact aerobics are encouraged in order to increase bone mass and decrease the risk of osteoporosis. Rationale 2: Women who have endometriosis or fibroids should be cautioned on the use of phytoestrogens Rationale 3: Peri- and postmenopausal women are advised to have a calcium intake of at least 1200 mg per day. Most women require supplements to achieve this level. Rationale 4: Research suggests that isoflavones, which are found in soy, are effective in reducing symptoms of insomnia in postmenopausal women. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Learning Outcome: LO06 – Explain the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Type: MCSA The charge nurse has received a shift change report. Which patient requires immediate intervention? Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 1. Multip at 6 cm undergoing induction of labor, strong contractions every three minutes 2. Primip at 4 cm whose fetus is in a longitudinal lie with an cephalic presentation 3. Multip at 10 cm and fetus at +2 station experiencing a strong expulsion urge 4. Primip at 3 cm screaming in fear because her mother died during childbirth Correct Answer: 4 Rationale 1: Strong contractions every three minutes are an adequate labor pattern during induction of labor. This patient is experiencing no complications. Rationale 2: Longitudinal lie with cephalic presentation is a head-down position. This is expected. Rationale 3: 10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected. Rationale 4: This patient is most likely fearful that she will die during labor if her mother died during childbirth. It is very rare to die during childbirth in developing countries. The extreme fear this patient is experiencing could stimulate the fight-or- flight mechanism and hormone cascade, which can significantly slow the progress of her labor; screaming and muscle tension increase the body’s oxygen consumption, and in extreme cases can lead to fetal hypoxia. This patient requires education and a great deal of support and is therefore the top priority. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 – Summarize the implications of abnormalities present in each of the five critical factors on the outcome of labor and the health of the expectant woman and the fetus. Question 3 Type: MCSA The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in three hours of contractions occurring every five minutes. The best response by the nurse is: 1. “Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress.” 2. “When your perineal body thins out, your cervix will begin to dilate much faster than it is now.” 3. “What did you expect? You’ve only had contractions for a few hours. Labor takes time.” 4. “The hormones that cause labor to begin are just getting to be at levels that will change your cervix.” Correct Answer: 1 Rationale 1: Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much less time than for subsequent labor and births. Rationale 2: The perineal body thinning primarily occurs during the second stage of labor; it is not expected now. Rationale 3: This reply is not therapeutic. Although it is true that this patient has only been in early labor for a short time, and it is true that labor for a primip averages 12– 24 hours, the nurse must always be therapeutic in all communication. Rationale 4: The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Learning Outcome: LO04 – Assess for the premonitory signs of labor when caring for an expectant woman. Question 6 Type: MCSA A 25-year-old woman is 38 weeks’ gestation with her first pregnancy. For the third time in one week, she presents to the hospital with complaints that are determined to be suggestive of false labor. Prior to discharge, the patient states, “I’m so embarrassed for thinking I was in labor. I feel like a fool.” What is the nurse’s best response? 1. “We’ll discuss the differences between true labor and false labor so this doesn’t happen again.” 2. “It’s impossible to distinguish between false labor and true labor.” 3. “Don’t feel bad. Everyone makes mistakes sometimes.” 4. “It’s very difficult to tell the difference between true and false labor. Please know we’re here to take care of you whenever you need us.” Correct Answer: 4 Rationale 1: Rather than reinforcing the woman’s incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman’s embarrassment. Rationale 2: While it may be difficult to subjectively distinguish between false labor and true labor, vaginal examination can be performed to determine if cervical dilatation is occurring. Rationale 3: Instead of reinforcing the woman’s perception of having made an error, the nurse should reassure her that her embarrassment is unwarranted. Rationale 4: Rather than reinforcing the woman’s incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman’s embarrassment. Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 – Differentiate between false and true labor in an expectant woman. Question 7 Type: MCMA The nurse is teaching a prenatal class about false labor. The nurse should teach patients that false labor most likely will include which of the following? Standard Text: Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Increased thin vaginal secretions Correct Answer: 1,4 Rationale 1: True labor contractions intensify while walking. Rationale 2: True labor results in increased intensity and frequency of contractions. Rationale 3: True labor results in progressive dilation. Rationale 4: True labor results in pain beginning low in the abdomen and radiating Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 upward or into the back. Rationale 5: True labor results in an increase in vaginal secretions. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 – Differentiate between false and true labor in an expectant woman. Question 8 Type: MCSA The nurse is caring for a laboring patient. A cervical exam indicates 8 cm dilation. The patient is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the patient alone so she can rest. 2. Ask the family to take a coffee and snack break. 3. Encourage the patient to have an epidural for pain. 4. Reassure the patient that she will not be left alone. Correct Answer: 4 Rationale 1: The patient is in the transitional phase of the first stage of labor and will not want to be alone. Rationale 2: The patient is in the transitional phase of the first stage of labor. The family members might want to take a break, but the patient will not want to be alone. Rationale 3: The patient is in the transitional phase of the first stage of labor. There is no indication that the patient wants pain relief. Rationale 4: Because the patient is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the patient and reassuring her that she will not be alone are the highest priorities at this time. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 – Describe the physiologic changes occurring in an expectant woman during each stage of labor in the nursing care management of the expectant woman. Question 9 Type: MCSA During the fourth stage of labor, your patient’s assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse should be to: 1. Turn the patient onto her left side. 2. Place the bed in Trendelenburg position. 3. Massage the fundus. 4. Continue to monitor. Correct Answer: 4 Rationale 1: A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. Rationale 2: Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. Rationale 3: The uterus should be midline and firm; massage is not necessary. Rationale 4: The patient’s assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. Global Rationale: Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 first stage of labor. Contacting the supervisor is required only when an abnormal situation is present. Rationale 4: Patients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present. Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 – Predict an expectant mother’s progression through the various stages of labor based on assessment data. Question 12 Type: MCSA Which patient requires immediate intervention by the labor and delivery nurse? 1. Multip at 8 cm, systolic blood pressure has increased 35 mm Hg 2. Primip that delivered one hour ago with WBC of 50,000 3. Multip at 5 cm with a respiratory rate of 22 between contractions 4. Primip in active labor with urine output of 100 ml/hour Correct Answer: 2 Rationale 1: The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor. Rationale 2: A white count of 25,000–30,000 is normal at the end of labor and during the early postpartum period. This white count is abnormally high and requires further assessment and provider notification. Rationale 3: The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This patient requires no further intervention. Rationale 4: This is a normal urine output and requires no further intervention. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 – Explain the maternal systemic responses to labor in the nursing care of an expectant woman. Question 13 Type: MCSA The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? 1. Increased pulse 2. Elevated blood pressure 3. Muscle tension 4. Increased respirations Correct Answer: 3 Rationale 1: Increased pulse is a manifestation of pain, but it does not impede labor. Rationale 2: Elevated blood pressure is a manifestation of pain, but it does not impede labor. Rationale 3: Muscle tension can impede labor progress by increased oxygen and calorie consumption and by creating a mechanical obstruction that the uterine contractions must overcome to achieve labor progress. Rationale 4: Increased respiration is a manifestation of pain, but it does not impede labor. Global Rationale: Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition 2022 Cognitive Level: Applying