Labor and Delivery: Key Indicators and Best Practices, Exams of Nursing

Download Labor and Delivery: Key Indicators and Best Practices and more Exams Nursing in PDF only on Docsity! 1 RNC-OB Exam Test Bank | Inpatient Obstetric Nurse Exam Prep 2024: RNC Study Guide + 350 Test Questions and Answer with Explanations 1. Late in pregnancy, a patient often develops supine hypotension because of a. partial occlusion of the vena cava and aorta. b. decreased peripheral collateral circulation. c. increased blood flow to the placenta. - A because of partial occlusion of the vena cava and aorta from the weight of the uterus. This impedes venous return from the lower extremities although increased collateral circulation during pregnancy helps to compensate. Remaining in the supine position for long periods of time could decrease fetal oxygenation as well. The lateral recumbent position relieves the pressure on the vena cava and aorta, allowing the blood pressure to increase and symptoms to decrease. The nurse must educate the new mother that a contraindication to breast feeding is a. fetal macrosomia. b. type II diabetes. c. infection with HIV/AIDS. - C Some maternal contraindications to breastfeeding include: -Infection with HIV/AIDS -Use of antiretroviral medications -Active TB not treated -Infection with human T-cell lymphotropic virus -Illicit drug use -Use of chemotherapeutic agents -Radiation therapy (may require only interruption during treatment) -Use of other medications that pass into the breast milk and may harm the child -Presence of herpes on the breast -Presence of varicella lesions on the breast (may resume after lesions crust) The initial postpartal intervention indicated for a soft boggy uterus is to a. apply an ice compress. b. massage the fundus until firm. c. apply a warm compress. - B 2 ...with the dominant hand while supporting the inferior uterus with the non-dominant hand to prevent trauma. If the fundus does not contract with massage, then further evaluation is indicated to determine if placental fragments remain. After the fundus becomes contracted, the nurse should push firmly downward on the fundus to expel clots that may have pooled. With the vibroacoustic stimulation test, stimulus with an artificial larynx or other device is applied to the maternal abdomen for a. 1 to 3 seconds. b. 5 to 10 seconds. c.1 to 2 minutes. - A Usually, stimulus is applied for 1-2 seconds and repeated up to 3 times with time extending to 3 seconds in order to stimulate fetal movement. A positive or reactive finding is an increased fetal heart rate of 15 bpm or more for at least 15 seconds; however, a nonreactive result does not always indicate fetal abnormality but indicates the need for further testing. Absence of the Moro reflex on one side only in a neonate may indicate a. fractured scapula. b. cerebral palsy. c. fractured clavicle. - C a fractured clavicle or brachial plexus injury. Damage to the central nervous system, such as may occur with cerebral palsy, often results in bilateral absence of the reflex. The Moro reflex is elicited by allowing the infant's head and trunk to fall slightly backward when the infant is raised. A positive Moro reflex includes immediate extension and abduction of the arms(and sometimes the legs) with fingers fanning and forming a C-shape with a return of the limbs to the flexed states In a multiparous woman, what is the lowest Bishop score that predicts labor induction will be successful? a. 5 b. 7 c. 9 - A In a multiparous woman, the Bishop score that predicts that labor induction will be successful is 5 or more while it is a 9 or more for a nulliparous woman. The Bishop score is a rating system to determine readiness for induction based on scores of 0-3 in 5 a. Epidural b. Spinal c. Pudendal block - A The epidural can provide continuous relief during both labor and delivery and does not pose the risk of spinal headache and provides less motor blockade. Additionally, there is a deceased risk of hypotension because of reduced risk of sympathetic blockade. Spinal is now usually reserved for Cesareans. The pudendal block provides relief primarily during delivery. A patient with lupus erythematosus places the fetus at risk if she takes which medication during pregnancy? a. Prednisone b. Methotrexate c. Plaquenil® (hydroxychloroquine) - B ...methotrexate or cyclophosphamide. Both of these medications should be discontinued at least 30 days prior to the patient becoming pregnant. Plaquenil and prednisone may be continued during pregnancy. A patient with lupus should be stabilized for at least 6 months before attempting to become pregnant because pregnancy may exacerbate symptoms, and the patient may have antibodies that increase risk of miscarriage or stillbirth in late pregnancy. A series of ultrasound scans after the 20th week show that the fetal head is growing normally but the abdominal circumference is lower than expected. This may indicated which of the following? a. Down syndrome b. Neural tube defect c. Placental insufficiency - C ...common in patients who are diabetic, hypertensive, or anemic. With placental insufficiency, the supply of oxygen and nutrients to the fetus is impaired, so the fetus responds by sending the nutrients to the most critical organs (heart, brain, lungs) and the other abdominal organs receive less, so they develop more slowly Idiopathic cardiomyopathy of pregnancy is a condition that a. precedes pregnancy and exacerbates due to the stress of pregnancy. b. develops in the last month of pregnancy or soon after birth without preexisting cardiac disease. 6 c. develops in the first trimester of pregnancy and must be monitored throughout the pregnancy and delivery. - B Develops in the last month of pregnancy or the first 5-6 postpartal months and is not associated with pre-existing myocarditis, endocarditis, or cardiac disease. It is characterized by left ventricular systolic dysfunction. Typical symptoms are similar to heart failure and include dyspnea (the most common symptom), orthopnea, cough, palpitations, and chest pain. The heart is markedly enlarged, and the ejection fraction is less than 45%. It increases risk of thromboembolia, so the woman is often treated with heparin. Treatment is similar to that for heart failure although if it occurs prior to delivery, ACE inhibitors are withheld because of adverse effects to the fetus. Management includes bedrest, diuretics, and digoxin. If 10% to 20% of the placental surface is detached but the mother and fetus are not in distress, the placental abruption is classified as a. grade 1, mild. b. grade 2, moderate. c. grade 3, severe. - A Grade 1: 10-20% of the placental surface is detached o the mother and fetus are not in distress. Uterus may be tender and mild tetany evident Grade 2: 20-50% is detached with or without external bleeding. Uterine tenderness and tetany are evident. While the mother is not in shock, the fetus shows distress. Grade 3: over 50% detached with severe uterine tetany, maternal shock, and frequently coagulopathy. The fetus is dead. If vaginal fluid contains blood, the nitrazine test for the presence of amniotic fluid a. may show a false positive. b. may show a false negative. c. is unaffected by blood. - A because the pH of blood ranges from 7.35-7.45 and the pH of amniotic fluid ranges from 7.0-7.5, so they may react similarly. A pH in the range of 6.57.5 is considered positive for amniotic fluid in the absence of other factors (blood, semen, urine) that may affect results. The test sample should include vaginal secretions from the posterior vagina but not the mucous plug 7 To reduce the risk of hemorrhagic disease after birth, a neonate should receive a. vitamin B9 (folic acid). b. vitamin C. c. vitamin K. - C Neonates are born with low levels of vitamin K, which is necessary to activate clotting factors. Additionally, while platelet levels are near adult level, the platelets do not respond effectively to stimuli for several days after birth. Combined, these factors increase the risk of hemorrhage, but the risk is markedly reduced if the neonate receives an IM injection of vitamin K. A patient is in active labor and has contractions every 8 minutes lasting for 45 seconds and increasing in intensity by 25 mm Hg during contractions. This patient is likely experiencing a. hypertonic labor. b. hypotonic labor. c. normal labor. - B The average amplitude is 40-50 mmHG. Because the contractions are often irregular and have low amplitude, cervical dilation is usually slowed or may arrest so that labor becomes prolonged without interventions. Treatment may include ROM and/or oxytocin to strengthen the contractions A pregnant patient who presents with sudden onset of severe uterine pain with slow increase in fundal height but no vaginal bleeding should be assessed for a. abruptio placentae. b. bladder retention. c. fecal impaction. - A Up to 80% of patients with abruptio placentae exhibit vaginal bleeding, but bleeding may be contained between the uterine wall and the placenta, resulting in maternal shock without obvious bleeding. If the fetus is at term, bleeding is severe, or the mother or fetus is in jeopardy, immediate delivery is indicated. During the second stage of labor, when does external rotation occur? a. As the fetus descends from station 2+ to 4+ b. Before delivery of the head c. After delivery of the head - C 10 During the fourth stage of labor, lochia should generally not exceed a. one saturated pad per hour. b. one saturated pad per 2 hours. c. two saturated pads per hour. - A ...as excessive drainage may indicate hemorrhage. Small clots are common in the lochia rubra, but large clots may indicate excessive bleeding. When changing the pad, it's important to examine the buttocks and back to determine if overflow drainage has pooled. If the uterus is firm but there is a continuous trickle of bright red blood, this may be an indication of laceration. When determining the baseline fetal heart rate, the fetal heart must be monitored for at least a. 2 minutes. b. 5 minutes. c. 10 minutes. - C The baseline rate is the average rate during that time period, rounded to the nearest 5 bpm. The normal fetal heart rate is 110-160 bpm at term with a slightly increased rate for the preterm fetus. Fetal tachycardia is defined as either over 150 bpm or over 160 bpm for at least 10 minutes, while bradycardia is defined as either under 110 bpm or under 120 bpm for at least 10 minutes The most common visual complaint during pregnancy is a. myopia. b. blurred vision. c. hyperopia. - B The pregnancy woman tends to retain fluid, and this retention along with decreased intraocular pressure causes some thickening of the cornea and change of shape during the first trimester, resulting in blurring of vision. However, these changes usually resolve within the first 8 weeks of pregnancy, so the visual changes should not be causes for changing prescriptions for corrective lenses. Pregnant women also commonly complain of dry eyes, which may be relieved by the use of artificial tears. With battledore placenta, the greatest maternal risks are for a. preterm labor and bleeding. b. postpartal hemorrhage. 11 c. late abortion and pre-term labor. - A The umbilical cord inserts into the placenta at or near the placental margin. Maternal risks include preterm labor and bleeding. Risks to the fetus include prematurity and fetal stress. Succenturiate placenta is at least 1 accessory lobe of fetal villi develops on the placenta. Maternal risk includes postpartal hemorrhage although there are few fetal risks Circumvallate placenta is a ring of chorion and amnion that surround the umbilical cord on the fetal side of the placenta. Maternal risks include late abortion, antepartal hemorrhage, and pre-term labor. Fetal risks include IUGR, preterm birth and mortality. When a woman is using paced breathing during labor, the rate of breathing should be no more than a. one and a half times normal rate. b. two times normal rate. c. three times normal rate. - B ...because a faster rate may result in hyperventilation. If using slow-placed breathing, the rate should be no slower than half the normal rate (usually 6-9 breaths per minute) to ensure that oxygenation remains adequate. Breathing during the first stage of labor may include cleansing breaths, slow-paced, modified paced, and pattern paced ("hee hoo") breathing. Breathing in short puffs may help control the urge to push. The cervix is considered uneffaced at a. 2 cm. b. 3 cm. c. 4 cm. - C The cervix is considered uneffaced at 4 cm (0% effacement). Effacement refers to thinning of the cervix, with the length of the cervix expressed in numbers of centimeters, and the degree of effacement in percentages. Complete effacement (100%) occurs when the cervix has completely thinned. Some patients efface slowly over the weeks prior to labor, especially if the fetal head is in the pelvis and applying pressure to the cervix, but others efface after onset of labor. During pregnancy, where are vascular spiders most common? a. Face, arms, and upper torso b. Abdomen, breasts, and thighs 12 c. Palms of the hands - A spider like vessels from dilated arterioles and small veins surrounding the arteriole filled with blood. They are most common on the face, arms, and upper torso and may occur in pregnant women because of increased levels of estrogen, so they recede after delivery. Palmar erythema (redness of the palms) is also caused by increased estrogen levels. Striae gravidarum (stretch marks) occur on the abdomen, breasts, and thighs and are caused by stretching of the skin Edema of the fetal scalp resulting from pressure of the head against the cervix is called a. cephalohematoma. b. caput succedaneum. c. molding. - B ...or from suction of vacuum-assisted delivery. The swelling crosses suture lines and is usually soft and resolves within the first 12 hours after delivery. Cephalohematoma is bleeding between the periosteum and the skull. The welling is usually firm, most commonly over parietal areas and does not cross suture lines. Molding is an overlappling of cranial bones at suture lines. This condition usually resolves within a week. An extra-long umbilical cord often results in a. fetal death. b. transient decelerations. c. umbilical cord rupture. - B ...because of knots that have formed. The average length of the umbilical cord is 55 cm. A longer cord rarely results in fetal death, but knots can form in the cord if the fetus is active and, although these are rarely pulled tight enough to completely restrict blood flow, they may tighten during contractions, resulting in decelerations. Knots are more likely to form in identical-twin pregnancies than singleton. The fetal head is considered engaged at which station? a. -1 b. 0 c. +1 - B ..., the level of the ischial spines. Station refers to the position of the presenting part in relation to the ischial spines. If the presenting part is above station zero, then the 15 A maternal indication of amniotic fluid embolism is a. respiratory distress. b. hypertension. c. hypertonic uterus. - A Amniotic fluid embolism occurs when a bolus of amniotic fluid with particles of debris, such as hair or meconium, enters the maternal blood and travels to the lungs, most commonly after rupture of the membranes. Thick meconium, which can clog the pulmonary vein, poses the most risk. Patients may develop coagulopathy with DIC. The amniotic fluid may also cause maternal venospasm and pulmonary hypertension, leading to left ventricular failure. The first stage of labor is the time period between onset of labor and a. cervical dilation of 8 cm. b. cervical dilation of 10 cm. c. delivery of infant - B Phases: -Latent: may vary widely in duration but is commonly 10-12 hours in multiparas and about 20 hours in primigravidas. The cervix begins effacement and contractions increase in frequency and intensity. -Active: The cervix dilation is 3-4 cm at onset and 8-9 cm at the end with this phase lasting about 5 hours for primigravidas and 2 hours for multiparas. -Deceleration phase: Dilation completes and delivery is imminent. Fetal tone evaluates a. extension and return to flexion. b. gross body movements. c. fetal resting position. - A To be scored as normal tone (2) in a BPP, the fetus should exhibit at least one episode of extension with return to flexion of limbs/trunk or lands. Fetal tone is scored as absent (0) if there is no movement or if there is slow extension with partial return flexion or movement of a limb in full extension. If the mother is Rh- and the father Rh+, what are the odds that the fetus will be Rh+? a. 25% b. 50% 16 c. 100% - C ...because every fetus will receive the Rh+ antigen from the father who provides half of the genetic makeup. With a first pregnancy, typically the fetus develops no problems because antibodies have not yet formed against the Rh+ antigen, but subsequent pregnancies are at high risk for the development of erythroblastosis fetalis, a hemolytic disease, unless the mother receives RhoGAM (Rh immune globulin) during the first pregnancy at 28 weeks gestation and within 3 days after delivery. The purpose of the Leopold maneuvers is to determine fetal a. movement, size, and presentation. b. lie, presentation, and position. c. size, lie, and presentation. - B -Lie: long axis of fetus in relation to long axis of mother, typically longitudinal (99%), although may be transverse or on rare occasions oblique -Presentation: refers to the presenting part, usually cephalic or breech with longitudinal lie Position: refers to the relation of the presenting part to the maternal pelvis, typically left or right. If the presenting part faces anteriorly or posteriorly, this is referred as anterior or posterior asynclitism. The last fetal system to mature functionally is the a. cardiovascular. b. renal. c. respiratory. - C ....so assessment of the respiratory system is especially important for preterm births under 36 weeks. If the respiratory system is immature, the neonate is unable to adequately ventilate the lungs and lacks adequate surfactant (phospholipids), which lower surface tension in alveolar sacs and facilitate ventilation This condition is referred to as respiratory distress syndrome (RDS). With RDS, the neonate may exhibit chest retraction, nasal flaring, grunting respirations, and hypoxia. A common problem in the mouth during pregnancy is a. gingivitis. b. tooth demineralization. c. decreased saliva. - A 17 ....because of hyperemia of the mouth and gum tissues resulting from increased levels of estrogen. Some patients may develop red, swollen, bleeding gums because of vascular hypertrophy, but these conditions recede after delivery of the fetus. Excessive salivation (ptyalism) is also common, although the cause is unknown. Demineralization of the teeth is not associated pregnancy although it is a common belief. The most frequent cause of postpartal hemorrhage is a. vaginal laceration. b. uterine atony. c. retained placental fragments. - B 90%. Following delivery, uterine contractions are needed to compress vessels and prevent bleeding from the placenta attachment site, but with uterine atony, the contractions are absent or ineffective. Predisposing factors induce distended uterus (multiple gestations and hydramnios), precipitous and prolonged labor, and administration of magnesium sulfate. The uterus may respond to massage, oxytocin, or Methergine (methylergonovine maleate), but surgical intervention (ligation of vessels, repair of lacerations, selective arterial embolization, or hysterectomy) may be required. Cervical effacement often begins a. before the onset of true labor. b. at the onset of true labor. c. after the onset of true labor. - A ...especially in the multiparous patient. As the cervix begins to efface, bloody show (blood-tinged mucous plug), which has served as a barrier to the cervical canal, is passed, sometimes all at once but at other times over a number of days. This usually occurs late in pregnancy and indicates cervical effacement is occurring. Effacement usually increases as lightening occurs with resultant increased pressure on the cervix and as Braxton Hicks contractions occur more frequently. Patients in labor are usually advised to come to the hospital when a. contractions occur every 10 minutes for at least an hour. b. the membranes rupture. c. bloody show occurs. - B 20 Following birth of an infant, signs of placental separation usually begin within a. 5 minutes. b. 15 minutes. c. 30 minutes. - A ....but it may take up to 30 min to expel the placenta and membranes. Signs include globular shaped uterus, rise in fundus, sudden expelling of a gush of blood or a trickle of blood, and extended length of the umbilical cord as it is pushed exteriorly by the descending placenta. The placenta may separate from the middle to the edges and be expelled with the fetal side presenting (Schultze mechanism) or may separate from the outer edges, rolling and present with the maternal side (Duncan mechanism). A tocotransducer detects a. intensity of uterine contractions. b. frequency and duration of uterine contractions. c. resting tone of the uterus between contractions. - B The toco has a pressure sensitive area that detects changes in the contour of the abdomen that occur with contractions. The sensor may also detect other movements, such as those associated with maternal respirations and fetal movements. The toco cannot provide a reliable estimate of the intensity of uterine contractions or the resting tone, and different maternal positions may affect the pressure against the toco. Prior to induction, it is most essential to assess for a. cephalopelvic disproportion. b. psychological status. c. macrosomia. - A ....(CPD) and fetal malpresentation because vaginal birth may not be possible and Cesarean may be required rather than induction. CPD may result from increased size of the fetus or from abnormally shaped or small pelvis. Both (vaginal assessment of pelvic bones to determine pelvic size) and ultrasound may be used to assess for CPD, but examination is often inaccurate before labor because fetal molding may alter the proportions. A patient who has hypertonic labor and is not progressing but experiencing a prolonged latent phase, increasing pain, and fatigue is likely a candidate for 21 a. Caesarean. b. increased sedation. c. induction. - C ...unless contraindications, such as extreme fatigue or cephalopelvic disproportion (CPD), are present. With hypertonic labor, the uterus does not adequately relax following contractions, and contractions are painful and ineffective so that effacement and dilation do not occur adequately. Induction with oxytocin is often used to strengthen the contractions. A multiparous patient who is in active labor and dilating 0.8 cm per hour is likely experiencing a. prolonged labor. b. normal labor. c. precipitous labor. - A ....because the multiparous patient usually dilates approximately 1.5 cm per hour and the nulliparous patient 1.2 cm per hour. The patient should be assessed for hypertonic and hypotonic labor patterns as well as other complications, such as abnormalities in fetal presentation or size, to determine the cause of the prolonged labor. Following precipitous labor and birth, the mother is most as risk for a. hypertension. b. hemorrhage. c. retained placenta. - B ...which is defined as at least 500 mL of blood loss after vaginal delivery or more than 1000 mL of blood loss after Cesarean. The hematocrit may show greater than 10% change from admission values. With hemorrhage, the patient is at increased risk for hypovolemic shock. Immediate treatment includes providing increased intravenous fluids, elevated feet and legs, and exploring the cause of bleeding, such as vaginal lacerations or retained placental fragments. Post-term pregnancy extends more than how many weeks? a. 40 b. 41 c. 42 - C ...or 294 days after last menstrual period. Increased risks for both the mother and the fetus occur during labor and delivery. Labor is often induced, and delivery is more 22 likely to include the use of forceps or vacuum-assisted delivery because the fetus is large for gestation age (LGA) or macrosomic. Cesarean may be indicated for cephalopelvic disproportion (CPD) or malpresentation. The minimum anesthesia usually needed for forceps-assisted delivery is a. spinal block. b. pudendal block. c. general anesthesia. - B Although forceps-assisted delivery is sometimes carried out with only local anesthetic, most patients cannot tolerate the use of forceps well without a minimum of a pudendal block. Regional anesthesia may be used in some circumstances and general anesthesia poses increased risk to the fetus. The criteria for forceps application, including the fetus's position, station, and presentation, should be reviewed to ensure that the patient is a candidate prior to forceps-assisted delivery. What is an indication for vacuum-assisted delivery of a fetus? a. Extended second stage of labor b. Advanced cranial molding c. Uncertain fetal station - A ...because longer duration correlates with increased maternal risk from trauma (hemorrhage, lacerations, and chorioamnionitis). Vacuum-assisted delivery may also be utilized if the mother's health or state of exhaustion precludes normal delivery and if there is suspected fetal compromise. Contraindications include advanced cranial molding, uncertain fetal station or position, and malpresentation. Relative contraindications include preterm fetus, overlapping cranial bones, cephalopelvic disproportion, and probable macrosomia. A pregnant woman with pre-eclampsia who develops petechiae, hematuria, and oozing of blood at IV insertions site, likely has a. sepsis. b. coagulopathy. c. anemia. - B ...such as disseminated intravascular coagulation (DIC). DIC is an emergent condition that occurs secondary to another disorder, so immediate assessment should include coagulation studies. The patient should be tilted toward the left to increase 25 A mother's smoking during pregnancy places the fetus at increased risk of a. low birth weight. b. renal abnormalities. c. bradycardia. - A ...and preterm birth. In addition, miscarriages and stillbirths are more common, and the fetus may exhibit tachycardia, respiratory problems, and birth defects. After birth, the child of a smoker is at increased risk of sudden infant death syndrome. The more that a pregnant woman smokes, the greater the risk, so all pregnant women should be advised to stop smoking during pregnancy. Second-hand smoke after delivery continues to pose risks to the infant. Prior to delivery, a patient with immune thrombocytopenia (ITP) should have what minimum platelet count? a. 30,000 mm3 b. 50,000 mm3 c. 100,000 mm3 - B ...because of the risk of bleeding if a Cesarean is required. With a platelet count of at least 30,000 mm3, treatment is usually withheld until 36 weeks gestation or earlier if birth is expected. The initial treatment is oral corticosteroids, usually started 10 days before anticipated due date or intravenous immunoglobulin. Transfusions are used only in emergent situations. Hypertension without proteinuria that develops after 20 or more weeks' gestation and persists 6 weeks into the postpartum period is classified as a. chronic hypertension. b. preeclampsia. c. gestational hypertension. - C AKA transient hypertension and pregnancy induced hypertension. If the hypertension persists more than 12 weeks PP, without any development of Pre-E, or if it began prior to 20 weeks, then the hypertension is classified as chronic rather than gestational. Therefore, the final diagnosis of hypertension may only be determined in the postpartal period When using the deep tendon reflex rating scale to assess CNS irritability secondary to preeclampsia, a low normal but diminished response is rated as what? a. 1+ 26 b. 2+ c. 3+ - A Assessment for hyperreflexia is done in the brachial, wrist, patellar, or Achilles tendons. Deep tendon reflex rating scale: 4+: Abnormal hyperactive, jerky, or clonic response 3+: More brisk than usual response but may be normal 2+: Normal 1+: Low normal response, diminished 0: Abnormal finding, no response Which cardiac abnormality poses the least maternal risk during pregnancy? a. Atrial septal defect b. Moderate aortic stenosis c. Marfan syndrome with aortic root involvement - A ...are the most common cardiac abnormality in pregnant women. With previous surgical repair, there is little increased increased risk to the patient. Without previous surgical repair, the patient is at increased risk for deep vein thrombosis and may also be at risk for bacterial endocarditis. A pregnant patient >40 years has increased risk of developing atrial flutter or atrial fibrillation. Moderate aortic stenosis poses an intermediate risk to the patient, and Marfan syndrome with aortic root involvement poses a high risk. What is the treatment of choice for a pregnant patient with Graves' disease? a. Methimazole b. Radioactive iodine c. Propylthiouracil - C The lowest possible dose is administered because the drug may cause hypoparathyroidism in the fetus. Methimazole may also be used, but it is usually avoided because it causes aplasia cutis (scalp disorder) in the fetus. Radioactive iodine is contraindicated during pregnancy because it may result in damage to the fetal thyroid. If surgery is necessary, the thyroid gland can be removed in the second trimester. Iron deficiency anemia during pregnancy is usually treated with a. blood transfusion. b. ferrous sulfate, 325 mg orally daily. 27 c. iron dextran, intramuscular. - B Iron deficiency anemia during pregnancy, accounts for approximately 95% of cases of anemia, is usually treated with oral ferrous sulfate, 325 mg orally daily. Higher or more frequent doses may result in GI upset and constipation and decreased absorption. If patients are unable to adequately absorb oral iron, then iron dextran 100 mg every other day for about 3 weeks may be administered IM. Transfusions are only indicated if severe symptoms, such as dyspnea, tachycardia, dizziness, are present. On day one of birth for a term infant, what is a normal blood glucose level? a. 40 to 60 mg/dL (2.2 to 3.3 mmol/L) b. 50 to 80 mg/dL (2.8 to 4.4 mmol/L) c. 60 to 100 mg/dL (3.3 to 5.6 mmol/L) - A ...increasing to 50-80 by day 2. Because capillary screening is less accurate than blood glucose, a low value should be verified by laboratory analysis. Typically, an infant is fed if values are 40-45 or less, especially with signs of hypoglycemia, and then the value rechecked 30-60 min after feedings until it remains above 50 twice. During pregnancy, a patient who is receiving hemodialysis for end-stage kidney disease should generally receive hemodialysis how often? a. 3 days a week b. 4 days a week c. 6 days a week - C ...instead of 3 days a week that is most common in non-pregnant patients in order to protect the fetus and because waste products from the fetus enter the maternal circulatory system. Only up to 7% of women receiving dialysis are able to conceive and 1:5 have spontaneous abortions, so pregnancies are high risk. Preterm birth, usually at about 32 weeks is common. Poor control of blood glucose levels during the third trimester in a patient with gestational diabetes increases the risk of a. preeclampsia. b. spontaneous abortion. c. congenital malformations. - A ...as well as fetal macrosomia, which may occur even with normal levels. Poor control of blood glucose levels in the first 10 weeks of pregnancy, when organs are 30 b. Hospitalization on bedrest until delivery of the child c. Caesarean section - A ...with the patient spending most of the time in bed and avoiding strain and sexual intercourse, which may trigger contractions and bleeding. With a second episode of bleeding, the patient is usually hospitalized until delivery of the child. Corticosteroids may be administered to help mature fetal lungs if delivery is necessary prior to 34 weeks. If severe bleeding occurs, Cesarean is indicated. For a preterm fetus at 31 weeks' gestation, what is considered an acceleration? a. Increase of at least 5 bpm for at least 5 seconds b. Increase of at least 10 bpm for at least 10 seconds c. Increase of at least 15 bpm for at least 15 seconds - B Accelerations is a temporary increase in fetal heart rate. Less than 32 weeks, a preterm infants' heart rate increases at least 10 bpm for at least 10 seconds. If the fetus is under 28 weeks, there is usually very little variability because the autonomic nervous system is still immature. If accelerations persist for more than 2 minutes, they are classified as prolonged. If the accelerations persist for more than 10 minutes, they are considered a change in the baseline rate. The most common cause of uterine inversion is a. multiple gestations. b. excessive cord traction. c. abruptio placentae. - B ...during expulsion of the placenta. The inversion may be partial or complete. The inverted uterus may be obvious if it protrudes from the cervical os or vaginal orifice, but other indications may be inability to palpate the fundus, maternal hypotension, and excessive vaginal bleeding. Initial treatment includes stopping oxytocic medications and reinserting the uterus manually (Johnson maneuver) after administration of medications, such as magnesium sulfate, to relax the uterine muscle. The primary complications related to multiple gestations are a. preterm birth and uterine inversion. b. preterm birth and uterine rupture. c. preterm birth and intrauterine growth restriction. - C 31 On average, twins are delivered at about 37 weeks gestation and triplets at 33 weeks, so they almost always have low birth weight, increasing risk of postnatal complications. Multiple fetuses tend to be smaller than singletons because the rate of growth slows earlier than with singletons: at 30-32 weeks for twins and 27-28 weeks for triplets. If retained placental fragments are suspected, the best method of to confirm the diagnosis is a. manual exploration b. ultrasound c. hysteroscopy - B In some cases, manual exploration may identify fragments, which can be loosened manually and removed. After expulsion of the placenta, it should be carefully examined for missing cotyledons to ensure it is intact. Retained fragments may occur if the placenta is forcefully separated during fundal massage prior to spontaneous separation. Retained fragments can prevent the uterus from contracting and compressing vessels, resulting in hemorrhage. What antimicrobial agent is contraindicated for treatment of bacterial infections during pregnancy? a. Fluoroquinolones b. Macrolides c. Penicillins - A ...as they may affect the musculoskeletal system of the fetus. Nitrofurantoin should be avoided in late stages of pregnancy as it may cause hemolytic anemia in the newborn. Tetracycline impairs development of fetal bones and teeth so it should only be used during the first trimester. Macrolides and penicillins are generally considered safe for pregnant women. The most common cause of fever greater than 38C/100.4F in the postpartal period is a. urinary tract infection b. respiratory infection c. genital tract infection - C ...usually of the uterine cavity and adjacent tissues (endometritis, metritis with pelvic cellulitis). Fever usually develops on the first or second day after delivery and persists. Manual removal of the placenta, membrane rupture, prolonged labor, 32 internal fetal monitoring, and Cesarean increase risk of infection. Multiple digital vaginal examinations are also a risk factor. Mortality rates are especially high for both mother (90%) and fetus (50%) with infection caused by group A-hemolytic streptococcus. If a mother suffers from severe postpartum depression and expresses intense dislike of her infant, the initial intervention should be to a. provide treatment for depression b. ask the mother if she plans to hurt her infant c. ensure safety of the infant - C The mother should not be left alone with the infant at any time until her condition improves. While treatment for maternal depression is appropriate, the condition may persist for weeks or months after treatment is initiated, and if the mother is experiencing some psychosis or inappropriate thoughts, she may not be forthcoming if asked about harming her infant If a neonate is bobbing his head and holding his hands in fists, this probably indicates a. neurological impairment b. hunger c. pain - B Signs of hunger may be subtle with crying (squawking) typically the last sign. Once an infant begins crying and acting frantic, the child may have difficulty latching on. Other signs of hunger include licking, sucking motions, rooting, bringing hands to mouth or face, and trying to suck a finger stroking the infant's cheek or lower lip. If the neonate is consistently underfed, the infant may become listless and show less interest in nursing. The type of breast milk that provides passive immunity to the neonate is a. colostrum b. transitional c. mature foremilk - A Colostrum, which is produced by the breast for the first 2-4 days, serves to provide passive immunity to the neonate through high levels of immunoglobulins (antibodies). Although colostrum, which is thick and buttery in appearance, is produced in low volume (teaspoons), it is three times higher in protein, because of antibodies, than mature milk and lower in fats and carbohydrates and is adequate for 35 c. measure the flow of blood from the uterine arteries to the placenta - C aka uterine artery Doppler. ... used to determine if placental insufficiency is present. The probe emits high-frequency sound waves, which are echoed back, and the frequency at which this occurs is translated into images and graphs that show blood flow. Doppler is used in conjunction with a placental ultrasound, which is done to determine the size and shape of the placenta as well as the placental location, umbilical cord insertion, and number of umbilical blood vessels. Fetal heart rate patterns are categorized as baseline, a. periodic, and episodic b. normal, and abnormal c. accelerated, and decelerated - A The baseline pattern must persist over at least 2 minutes in a 10 minute period and must exclude accelerations and decelerations or other types of variability. The baseline heart rate pattern is utilized when assessing changes, such as accelerations. Periodic heart rate patterns are those that occur during uterine contractions while episodic heart rate patterns are those that occur when the uterus is resting. When the nadir of a deceleration corresponds to the peak of the contraction, it is classified as a. late deceleration b. early deceleration c. variable deceleration - B -Early decelerations: The nadir of the deceleration corresponds to the peak of a contraction with the duration from onset to nadir is at least 30 seconds. The decrease in fetal heart rate is symmetrical and gradual. -Late decelerations: Similar to an early deceleration in appearance and duration except that the nadir follows the contraction. -Variable decelerations: Abrupt fall in heart rate below baseline greater than 15 bpm for at least 15 seconds but less than 2 minutes, occurring irrespective of contractions The anesthetic technique that poses the least risk to the fetus is a. spinal b. epidural 36 c. pudendal block - C ...which involves injection of a local anesthetic to block the pudendal nerve. The block is done in the second stage of labor, usually shortly before delivery to relieve perineal pain and pain associated with episiotomy. While risks to the fetus are minimal, it is possible to directly inject the anesthetic into the fetus. Some infants may show intoxication after delivery with hypotonia, apnea, and even seizures in severe cases, but the infant usually recovers well. A risk factor most commonly associated with artificial rupture of the membranes (amniotomy) after the head is engaged is a. infection b. hemorrhage c. breech delivery - A ...especially if labor is prolonged. If the amniotomy is done before the head is engaged to 0 station or more, then there is some risk that the fetus will turn to breech position. Another risk factor is prolapse of the umbilical cord. Some physicians provide antibiotic prophylaxis prior to amniotomy, but this practice has neither been supported nor refuted by research. The primary risk associated with a midline episiotomy is a. hemorrhage b. urinary incontinence c. laceration - C ...despite the fact that episiotomy is often done to prevent lacerations. Additionally, small lacerations often cause less discomfort than episiotomy and heal more rapidly. The episiotomy may extend into third or fourth degree lacerations, involving the rectal sphincter and mucosa. Episiotomy should not be done routinely to speed delivery but may be indicated with forceps-assisted delivery or arrested descent. Episiotomies may also be done with a mediolateral incision, but this is rarely done in the US. For forceps-assisted and vacuum-assisted delivery, if the leading edge of the fetal skull is at station +2 or lower, it is classified as a. outlet b. low c. midpelvis/midforceps - B 37 The classification system for assisted delivery includes specific criteria: -Outlet: Scalp is visible as fetal head is on perineum. Positions are ROA, LOA, ROP, or LOP. -Low: Leading edge of fetal skull at +2 station or lower. -Midpelvis/midforceps: Fetal head engaged and above +2 station. The most common complication that occurs because of excessive force on the fetal neck during delivery is a. brachial plexus injury b. spinal cord injury c. respiratory distress - A ...which is often associated with shoulder dystocia. Five degrees of injury include: -First: Stretching of nerve fibers with recovery within a few days -Second: Compression and swelling of the nerve with recovery usually complete but takes longer -Third: Damage to the nerve sheath with full recovery not possible -Fourth: Formation of a neuroma that interferes with never regeneration -Fifth: Complete loss of nerve function because of injury of the nerve at the spinal cord The Cesarean incision that carries the greatest risk of subsequent uterine rupture with vaginal birth is a. low transverse b. low vertical c. midline vertical (classic) - C Only patients with low transverse incisions, the most common type of incision currently done, are considered for vaginal birth after Cesarean (VBAC). Risk factors that preclude VBAC include small pelvis, previous Cesarean for prolonged labor, previous uterine rupture, and obstetric complications (such as placenta previa). A physician and anesthesiologist/anesthetist must be on site and available in case emergency Cesarean is required. The three classic signs of placental separation after delivery are 40 a. 2 hours b. 6 hours c. 12 hours - C During the first two hours after insertion, the patient should remain lying down so that the insertion stays in place. The insert, which is shaped like a thin tampon, is often used the night before a scheduled induction to begin cervical ripening. Cervidil should only be used when the patient is near due date or when induction is a medical necessity. Normal uterine activity is defined as a. no more than 5 uterine contractions in a 10 minute period of time averaged over a 30 minute period b. at least 5 uterine contractions in a 10 minute period of time averaged over a 30 minute period c. at least 8 uterine contractions in a 10 minute period of time averaged over a 30 minute period - A ...with at least 3 uterine contractions usually needed for effective labor. Tachysystole is defined as at least 5 uterine contractions in a 10 minute period of time averaged over a 30 minute period. While tachysystole may occur spontaneously, it may also result from assisted obstetrics procedures, such as amniotomy and use of oxytocin or misoprostol. Maternal hypertension and epidural anesthetics also increase risk of tachysystole. The most common reason for elevated bilirubin levels in a breastfed infant within a week of birth is a. fatty acids resulting from cold stress b. inadequate intake of breast milk c. immature gastrointestinal tract - B aka breastfeeding jaundice. If the child does not nurse adequately because of excessive sleepiness, poor sucking, or infrequent nursing, the child may not ingest enough colostrum to benefit from its laxative effect, which helps to eliminate meconium, which is high in bilirubin. The mother may need assistance with breastfeeding to increase the neonate's intake and the production of milk. If maternal hypotension occurs during labor, the initial response should be to a. administer a bolus of IV lactated Ringer's solution 41 b. reposition the patient to lateral position c. administer ephedrine 5-10 mg intravenously - B ...toward the left is preferable, but either side is acceptable because lying flat during labor increases the risk of maternal hypotension and decreases uteroplacental blood flow. If the patient remains hypotensive, then a bolus of IV lactated Ringer's solution may be administered. If hypotension persists despite the other interventions, then ephedrine 5-10 mg IV may be administered. A transient sinusoidal fetal heart rate pattern with slight increase of rate over baseline may occur after administration of a. magnesium sulfate b. terbutaline c. butorphanol - C aka Stadol. It is a synthetic opioid that is commonly used for intrapartum management of pain at usual dose of 1 mg every 3-4 hours. It may be administrated by IM, IV, or nasal spray. Because it has some narcotic antagonist effects, it can cause withdrawal symptoms in patients who are addicted to opiate drugs or if other narcotics have been administered previously. Which NICHD category predicts normal fetal acid-base status? a. I b. II c. III - A -Category I: Predicts normal fetal acid-base status with baseline fetal heart rate of 110-160, moderate baseline variability, and no late or variable decelerations although early decelerations may be evident. -Category II: Indeterminate classification with all tracings varying from both Category I and Category III findings. -Category III: Predicts abnormal fetal acid-base status with sinusoidal pattern and absent variability associated with recurrent late or variable decelerations or bradycardia. A comfort measure to reduce perineal edema in the immediate postpartal period is a. hot pack 42 b. ice pack c. Sitz bath - B ...especially for the first 24 hours As the edema subsides, then a Sitz bath may provide comfort, especially if the patient has had an episiotomy. Swelling that is localized on one side may indicate that the patient has a hematoma and should prompt immediate evaluation to determine the cause of the bleeding. When using the Silverman-Anderson index to score respiratory difficulty in a neonate, a score of 10 indicates a. severe respiratory distress b. mild to moderate respiratory distress c. normal respirations - A Five criteria, scored from 0 (normal) to 2 (severe) include chest/abdominal movement, intercostal spaces, xiphoid, nares, and expiratory sound. In a very obese pregnant patient, auscultation of the fetal heart rate usually requires a. stethoscope b. Doppler ultrasound c. fetoscope - B ...because the extra layers of abdominal fat muffle the fetal heart sounds. Doppler is most commonly used for external auscultation of the fetal heart rate in all patients because it is easy to use and may have a digital display. If the patient is giving birth under water, some Doppler devices can be used under water effectively. When preparing a patient for Cesarean, the internal fetal monitor is a. left in place until the abdominal incision is completed b. removed before the sterile abdominal skin prep c. removed after the sterile abdominal skin prep - C If an external monitor is used, it is removed before the skin prep. Other preparations may include antibiotic prophylaxis. If a low transverse incision is anticipated, then the pubic hair may be clipped. An indwelling catheter may be inserted to ensure that the bladder is empty in order to prevent damage to the bladder. During the fourth stage of labor immediately after birth, the diameter of the contracted uterus for a singleton birth on palpation should be approximately a. 10 to 15 cm 45 doesn't usually return to normal or the vaginal walls to prepregnancy thickness while breastfeeding. In the immediate postpartal period, a patient's white blood count increases from 15,000 mm3 to 28,000 mm3, probably indicating a. normal physiological response b. puerperal infection c. coagulation disorder - A Leukocytosis (up to 30,000 mm3) is common during labor and the early postpartal period with most of the increase attributed to neutrophils, which increase in response to inflammation and pain. The leukocytosis recedes and levels usually return to baseline normal by about 6 days after delivery. Patients often experience bradycardia during the early postpartal period because of a. hypovolemia b. anesthetic effects c. increased stroke volume - C Hypervolemia is generally present at term, offsetting blood lost during delivery. Transient increased cardiac output occurs after delivery when blood that had been diverted to the placenta returns back into maternal circulation. Additionally, circulation increases because of less pressure on the vessels. Cardiac output may remain elevated for about 48 hours after delivery, resulting in increased stroke volume. If a postpartal rubella antibody screen shows a patient is not immune to rubella, the patient should a. receive the vaccination in 28 days b. receive the vaccination immediately c. receive the vaccination after stopping breastfeeding - B Usually the screening is done prenatally although the patient cannot receive the vaccine during the pregnancy but is advised to receive it after childbirth to prevent risks to future pregnancies. Women who receive the vaccine should avoid becoming pregnant for at least 28 days after the vaccination because rubella vaccine contains a live virus. The best method for a patient to suppress lactation is to 46 a. wear a support bra and apply cold packs b. avoid wearing a bra and apply warm packs c. take estrogen for suppression - A The patient should also avoid anything that may stimulate production of milk, such as a warm shower or nipple stimulation. While medications were once routinely given to suppress lactation, they are usually avoided because of potential adverse effects. Ice packs or other cold compresses may help to depress milk production and relieve discomfort. While adapting to the maternal role, the puerperal phase in which the mother is most receptive to patient education is a. taking-in b. taking-hold c. letting go - B Taking in (1-2 days): The patient remains somewhat passive, tending to her own needs, taking in details about the neonate, and discussing labor and delivery. Taking hold (several days): The patient takes a more active role and questions her competence, seeking out information. This is the most teachable time. Letting go: The patient begins to let go of previous lifestyle and learns to accept the real infant as opposed to the one imagined. Before placing the intrauterine pressure catheter, the physician or midwife should review the maternal a. complete blood count b. platelet count c. ultrasound report - C ....to determine the location of the placenta because insertion of the catheter is contraindicated with placenta previa. Before catheter placement, the membranes must have ruptured spontaneously or by amniotomy. Once in place, the IUPC is connected to an electronic monitor. Normal resting pressure is 20 mmHg. Pressure ranges by phase: -Latent: 20-40 mmHg -Active: 50-70 mmHg -Transition: 70-90 mmHg 47 -Second Stage, pushing: 70-100 mmHg If a precipitous birth occurs and a nuchal cord is evident after delivery of the fetal head, the initial response should be to a. grasp the cord with curved fingers and pull it over fetal head b. double clamp and cut the cord c. keep fingers under the cord to pull it away from the neck - A In most cases, this maneuver is successful, but if it is not, then the cord should be double clamped and cut before delivery of the rest of the body to prevent asphyxia. The mother should be advised to pant and stop pushing until the cord is dealt with. Red splotchy areas with white papules in the center on the back and chest of a neonate 24 hours after delivery probably indicate a. nevus flammeus (port-wine stain) b. nevus vascularis (strawberry hemangioma) c. erythema toxicum - C ...sometimes up to 2 weeks. Usually disappears within a few hours or days. Nevus flammeus (port-wine stain) is a permanent pink to dark red to purple birthmark. Can occur throughout body. Nevus vascularis (strawberry hemangioma) is a raised dark red rough-surfaced lesion, usually on the scalp. Grows for 5-6 months but recedes by school age without treatment. Placing the newborn infant against the mother's bare skin helps to reduce a. evaporative heat loss b. conductive heat loss c. convective heat loss - B ...which occurs when the neonate contacts objects with lower temperature than the neonate's skin. Drying the neonate immediately helps prevent evaporative heat loss and providing a warm environment, free of drafts, helps prevent convective heat loss. Placing the child into a radiant warmer transfers heat from the warmer to the neonate through radiation. If a labor patient is standing during a contraction and having severe back pain, she should a. sit down b. lean forward 50 An indication of placenta previa is a. painless bleeding after 20 weeks' gestation b. tender uterus with increased resting tone c. hypertonic uterine contractions - A (implantation of the placenta on or near the internal cervical os) is painless bleeding after 20 weeks gestation. The woman is also at risk for hemorrhage in the third trimester. Placenta previa is classified as complete (covering the internal cervical os), partial, or marginal (to the edge of the internal cervical os). When diagnosed, bedrest is usually required. As the uterus expands, the implantation site may move away from the cervical os, correcting the condition. When using ultrasound to determine the estimated date of birth (EDB) for a pregnant woman whose menstrual cycles are irregular, the crown-rump length is most accurate at a. 4 to 6 weeks b. 6 to 10 weeks c. 12 to 18 weeks - B ...with accuracy of plus or minus 3-5 days. However, after about the 12th week of gestation, the fetus begins to curve, making the crown-rump length less accurate. Thus, after the first trimester, the estimated date of birth is obtained using three measures: femur length, abdominal circumference, and biparietal diameter. During the active phase of the first stage of labor, the patient should dilate to a. 2 to 3 cm b. 3 to 5 cm c. 4 to 7 cm - C (which follows the latent phase and precedes the transitional phase) of the first stage of labor. The nullipara typically dilates about 1.2 cm per hour while the multipara dilates 1.5 cm per hour. Contractions occur every 1-5 minutes and last for 40-60 seconds with contractions stronger, increasing both pain and anxiety. Most multiparous patients are admitted to labor and delivery in this phase, although nulliparous patients often are admitted earlier. An infant born to a mother who is positive for hepatitis B surface antigen should receive 51 a. hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth b. hepatitis B immune globulin within 12 hours of birth only c. hepatitis B vaccine within 12 hours of birth only - A The hepatitis B immune globulin will provide protection against the infection while the vaccine takes effect. All infants should receive 3 doses of hepatitis B vaccine. If the mother's status is unknown, the initial vaccine should be given within 12 hours of birth, but if the mother's status is negative, the initial vaccine may be given withing the first 2 months. A pregnant woman who is addicted to heroin and beginning treatment with buprenorphine should first be stabilized with a. morphine b. naloxone c. methadone - A ...because addicts rarely have a steady supply of heroin, so blood levels of the drug vacillate. Once the blood level is stabilized, then buprenorphine can be initiated under close supervision. Because buprenorphine crosses the placental barrier, the fetus develops opioid dependence and will undergo withdrawal after delivery, requiring treatment of the neonate with decreasing doses of morphine. Twelve hours postpartum, a patient's fundus is 2 centimeters above the umbilicus and boggy, likely indicating a. normal findings b. excessive bleeding c. distended bladder - B Within 6-12 hours after delivery, blood and clots pool in the uterus, causing it to rise to the level of the umbilicus, midline. After about 12 hours, the fundus lowers and should be about 1 cm below the umbilicus by the first postpartal day. If the fundus rises above the umbilicus but deviates to one side, this often indicated a distended bladder. After delivery, patients are most at risk of development of deep vein thrombosis a. for the first 3 days b. 1 week after delivery c. for the first 2 weeks - A 52 ...with thrombophlebitis evident at days 3-7. During pregnancy, fibrinolytic activity decreases, which also decreases the risk for hemorrhage, but coagulation does not return to normal for about 3 days after delivery, a time in which the mother may be relatively inactive or on bedrest, resulting in clot formation in vessel walls and resultant inflammation and occlusion. The appropriate endotracheal tube size (internal diameter) for a neonate of 30 weeks' gestation and 1,500 g is probably a. 2.5 mm b. 3 mm c. 4 mm - B In a resuscitation kit for neonates, endotracheal tube sizes should include tubes ranging from 2.5-4 mm. -2.5 mm: neonates less than 28 wks/less than 1000g -3 mm: neonates 26-34 wks/1000-2000g -3.5 mm: neonates 34-38 wks/2000-3000g -3.5-4 mm: neonates 38+ wks/3000g+ Most twin pregnancies are delivered at a. 30 weeks b. 34 weeks c. 37 weeks - C ...compared with an average of 40 weeks for singletons, so multiple gestation pregnancies are at risk of preterm delivery and must be monitored carefully. With each subsequent fetus, the duration of gestation decreases by about an additional 4 weeks, so the average gestation for triplets is 33 weeks. With twin pregnancies, the mother is asked to do a kick count beginning at about week 30-32 to assess fetal well- being. The cephalic presentation that generally requires a cesarean for delivery is a. face b. brow c. occiput - B ...because the average anterior-posterior diameter of this presentation is 13.5 cm while the largest diameter that generally is able to pass through the pelvis is about 9.5 cm. The occiput presentation (most normal) and face presentation both have anterior- 55 unable to urinate, a straight catheterization may be indicated to prevent bladder rupture during delivery. A pregnant patient who is in a methadone program to control drug addiction should be advised to a. stop taking methadone immediately b. slowly decrease dose of methadone and then stop taking c. continue taking methadone - C Abrupt withdrawal from methadone may result in death of the fetus. Ideally, the mother should decrease dosage until free of drugs, but pregnancy is a stressful time and not usually the best time to add the stress of eliminating drug use. While less dangerous to the fetus than heroin, methadone does cross the placental barrier and poses risks to the fetus, including IUGR, stillbirth, preterm birth, low birth rate, and fetal distress. For a fetal nonstress test (NST), the correct position for the mother is a. semi-Fowler with pillow under left hip b. semi-Fowler with pillow under right hip c. upright position with legs dependent - B ...to displace the uterus to the left. The mother should refrain from smoking before the rest but should be non-fasting. The test should be scheduled during the daytime hours when the fetus may be more active. An electronic fetal monitor is used to monitor the fetal heart rate and a tocodynamometer to detect uterine contractions or movement of the fetus. If shoulder dystocia occurs during delivery, the maternal positioning that may elevate the pubic bone is to a. lift and hyperflex thighs b. turn to left lateral Sims position c. extend both legs - A (McRoberts maneuver). Shoulder dystocia occurs when the head is delivered but the shoulders are not because they are blocked by the symphysis pubis. Shoulder dystocia may be assoicated with post-term pregnancies, macrosomia, assisted vaginal delivery, maternal diabetes, and protracted labor. Suprapubic pressure may be applied externally to facilitate delivery while traction is applied to the neonate or the neonate is manually rotated. An episiotomy may be necessary. 56 A patient with a Bishop score of 9 generally indicates that a. labor will not begin without induction b. induction will probably be unsuccessful c. labor will begin spontaneously - C Bishop scores range from 0-13. These scores are often used to determine if induction is necessary. If the score is 5 or less, then spontaneous labor is unlikely without induction. A score of 9 or more indicates that labor will most likely commence spontaneously. Scores between 5-9 require additional consideration and professional judgement for clinical management. The Bishop score is based on assessment of 5 parameters: dilation, effacement, station, cervical consistency (firm, medium, soft), and cervix position (posterior, mid-position, anterior) The hormone that most affects glucose metabolism during pregnancy, making control of type 1 diabetes difficult, is a. estrogen b. human placental lactogen c. progesterone - B ...which the placenta produces in large amounts as it enlarges. This hormone affects both fatty acid and glucose metabolism by increasing lipolysis and decreasing glucose uptake. Increased production of estrogen and progesterone can also interfere with the insulin-glucose relationship, and increased production of insulinase degrades insulin. Insulin levels may need to be adjusted to compensate for hormonal changes. A neonate who developed hyperbilirubinemia after delivery because of ABO incompatibility is at increased risk for development of a. anemia b. thrombocytopenia c. congestive heart failure - A While ABO incompatibility rarely results in serious fetal complications, the neonate may develop hyperbilirubinemia after delivery and should be monitored carefully; the infant may develop anemia in the weeks following delivery because of increased breakdown of red blood cells. ABO incompatibility occurs with the first pregnancy and does not worsen with subsequent pregnancies. Anti-A and anti-B antibodies, which occur as the mother is exposed to food or bacteria with A and B antigens, are 57 relatively large and do not easily enter fetal circulation, but smaller antibodies form if fetal blood leaks into maternal blood. In a normal singleton pregnancy with cephalic presentation, if the fundal height is palpated at 28 cm, the gestational age is approximately a. 22 weeks b. 28 weeks c. 32 weeks - B The fundal height in centimeters approximately corresponds to the gestational age in weeks if gestation is between 1-36 weeks. After 36 weeks, the uterus begins to change shape as the body prepares for delivery and the fetal head becomes engaged. At this time, the fundal height may even decrease or grow more slowly. The effect that maternal administration of narcotics has on the fetal heart rate is a. increase in baseline rates b. transient sinusoidal fetal rate and increase in baseline rate c. decreased variability and frequency of accelerations - C Medications that the mother receives may have an effect on the fetus. Some medications, such as butorphanol and terbutaline, may increase the baseline rate. Other such as magnesium sulfate, may decrease the baseline rate but these changes may be insignificant. Some drugs and substances used by the mother prior to labor (such as cocaine, amphetamine, and nicotine) may result in fetal tachycardia and decreased variability. The maternal serum screen should be done at a. 15 to 20 weeks b. 18 to 22 weeks c. 20 to 26 weeks - A The maternal serum test is a second trimester screening that is done between 15-20 weeks of gestation. Screening tests include: -First trimester: ultrasound at 8-12 weeks and noninvasive prenatal testing (NIPT) from 10 weeks, nuchal translucency at 11.5-13.5 weeks, and chorionic villus sampling at 11-13 weeks. -Second trimester: maternal screening test at 15-18 weeks, amniocentesis at 15-19 weeks, and ultrasound at 18-20 weeks. 60 c. April 24 - A ....one week after the due date, assuming the due date was calculated correctly. Most designations of post-term pregnancies result from inaccurate due date. Post-term pregnancies are more common with primigravidas than multipara. Post-term pregnancies increase risk of stillbirth and neonatal mortality. About 1/4 of post-term pregnancies are assoicated with macrosomia, common in infants of mothers with diabetes. Bloody show is an indication of a. extrusion of mucus from endocervical glands b. placental separation c. maternal bleeding because of alterations in coagulation - A ...with blood loss from cervical capillaries, often referred to as a mucus plug. Bloody show often occurs late in pregnancy after effacement has begun and may occur prior to the onset of true labor; bloody show is usually followed by labor within 24-48 hours. Blood-tinged discharge, usually brownish in color, noted on vaginal exam should not be confused with bloody show. With abruptio placentae, fetal death is common with separation of a. at least 15% b. at least 25% c. at least 50% - C (premature detachment of placenta from the uterus). It is associated with maternal hypertension and cocaine use. Intrauterine growth retardation occurs with partial detachment because the fetus lacks adequate nourishment. If total detachment occurs, hemorrhage may occur, with half of those affected exhibiting coagulopathy. Complications can include fetal distress, fetal death, hypotension, DIC, and maternal death. Partial placental abruption is treated with bedrest and monitoring; complete separation requires immediate vaginal delivery or cesarean. When a transabdominal ultrasound is used to localize the placenta for an amniocentesis in gestation week 32, the woman should generally be advised to a. empty the bladder before the procedure b. drink 1.5 to 2 quarts of water 2 hours prior to the procedure c. drink 3 to 4 glasses of water immediately prior to the procedure - A 61 If the amniocentesis is done early in pregnancy, then it is often done with a full bladder. A full bladder helps the examiner to assess other structures, such as the cervix and vagina, and is important if the patient is being assessed for vaginal bleeding or placenta previa. The first step in quality improvement measures on the nursing unit is to a. brainstorm methods to enhance the unit's level of care b. formulate a plan to implement quality-improvement measures c. identify the areas in need of improvement on the unit - C Begin with identifying those things in need of improvement. Without an assessment of needs, quality improvement measures may be misguided. This may begin with failure mode and effects analysis (FMEA), gap analysis, internal research (data analysis, surveys, interviews, observation), root-cause analysis, tracer methodology, or other methods of brainstorming. Once problems or areas for potential improvement are identified, then some method of brainstorming is used to generate solutions from which one or more is selected. Plans are formulated, tested, and implemented. Following implementation, the changes are monitored and modified as needed. During labor, if the presenting part has reached the level of the ischial spines, the station is a. 0 b. -1 c. +1 - A Station refers to the position of the presenting part in relation to the ischial spines, which are usually the narrowest area through which the fetus must pass during delivery. If the presenting part is higher than the level of the ischial spines, the station is designated with negative numbers (-1 to -5) with each number representing a centimeter. If the presenting part is below the level of the ischial spines, the station is designated with positive numbers (+1 to +5). A patient at 24 weeks' gestation with blood pressure (BP) 150/94 mm Hg and 0.4 g of protein in 2-hour urine specimen would be classified as having a. hypertension b. mild preeclampsia c. severe preeclampsia - B 62 Mild Pre-E: BP 140/90 or higher with BP previously normal and 0.3g or higher protein in a 2 hour urine specimen. Severe Pre-E (one or more of the following): BP 160/110 mm Hg or higher separated by 6 hours on bedrest. Proteinuria at least 5g per 24 hour urine specimen or at least 3+ in 2 random urine specimens at least 4 hours apart. Oliguria less than 500 mL per 24 hours, pulmonary edema/cyanosis, visual disturbances, thrombocytopenia, impaired liver function, or epigastric/RUQ pain. A patient nearing term who complains of low back pain may be experiencing a. false labor b. active labor c. either false or active labor - C In some cases, the pain is caused by the fetal position, with occiput posterior position causing pressure on the sacrum, resulting in severe pain. In other cases, the pain is unrelated to the fetal position. Walking or other activities, such as doing pelvic tilts or sitting on a birth ball, may help reposition the fetus and relieve the discomfort if the pain results from fetal position. Hot or cold compresses applied to the lower back, a hot shower, or massage may also help. A patient receiving an amniotomy to induce labor is also usually given a. oxytocin b. intravenous fluids c. steroids - A An amniotomy may be done when the cervix is ripe and the presenting part of the fetus is engaged or to speed labor if progress is slow. If used to induce labor, labor usually begins within 12 hours; however, if labor does not begin, the mother is at increased risk of infection and fetal malposition, so oxytocin is often given along with the amniotomy to ensure that labor commences. Uterine atony may result in a. uterine rupture b. uterine inversion c. hemorrhage - C ...because uterine contractions are needed to occlude blood flow to the placenta. Uterine atony is most common with overdistension of the uterus resulting from multiple gestation or macrosomia and from dysfunctional or prolonged labor 65 c. heroin withdrawal - B ....because methadone poses less danger to the fetus than heroin, which can result in iron-deficiency anemia, pre-E, eclampsia, preterm birth, early separation of the placenta, and breech presentation. Abruptly stopping heroin use cold turkey may result in onset of preterm labor, spontaneous abortion, or stillbirth, so transitioning to methadone under close supervision is the best option. Methadone may reduce cravings and delay withdrawal symptoms. The HELLP syndrome refers to hemolysis, elevated liver enzymes, and a. labor pain b. low platelet count c. large placenta - B Patients usually complain of pain in the epigastric or RUQ area of the abdomen. HELLP may occur in up to 20% of patients with pre-E or eclampsia. When diagnosed, the treatment of choice is to immediately deliver the infant (even if premature) as the condition may worsen rapidly and threaten both the mother and child. During uterine contractions, the fetal heart rate usually a. remains unchanged b. increases c. decreases - C The contractions result in compression of the head and decreased cerebral blood flow, effectively slowing the heart rate. Additionally, the contractions compress uterine myometrial vessels and may occlude the umbilical cord, causing hypertension in the fetus. Some medications given to control maternal pain or to stimulate contractions may also affect the heart rate, include opioids and oxytocin. Sources define bradycardia as being either less than 110 bpm or less than 120 bpm for at least 10 minutes with severe bradycardia begin less than 80 bpm. A common cause of symmetric intrauterine growth restriction (IUGR) is a. chromosomal abnormalities b. placental insufficiency c. preeclampsia - A The head and the body are both growth-restricted proportionately. This condition usually arises early in pregnancy because of chromosomal abnormalities or infections 66 that affect fetal growth. With asymmetric IUGR, the head is large and appropriate for gestational age, but the body is growth restricted. This condition usually arises because of placental insufficiency or pre-E that occurs late in pregnancy. IUGR is diagnosed prenatally with ultrasound. IUGR is often associated with oligohydramnios. After 20 weeks of gestation, amniotic fluid is primarily produced by a. maternal serum b. fetal excretion of urine c. fluids from fetal respiratory tract - B Thus, if the volume of amniotic fluid is low (oligo), less than 500 mL, urinary tract abnormality (renal agenesis, polycystic kidneys) or obstruction (obstructive uropathy) should be suspected. Other conditions associated with oligo include pulmonary hypoplasia, post-term gestation, meconium staining, umbilical cord compression, and prolonged leaking of amniotic fluid, increasing risk of neonatal infection. Adequate amniotic fluid is essential for normal pulmonary development. Diabetes mellitus during pregnancy increases the risk of a. oligohydramnios b. hydramnios c. microsomia - B ...which is an increased volume of amniotic fluid (AFI >24 cm, volume more than 1700 mL). Hydramnios occurs in about 10% of diabetes associated pregnancies. Normal AFI varies according to weeks of gestation with the average amount at 34 weeks of 800 mL (peak volume) but falling to 600 mL at 40 weeks. Polyhydramnios may result in preterm birth, malpositioning of the fetus because the fetus is essentially floating, prolapse of the umbilical cord, and abruptio placentae. When administering magnesium sulfate to a patient in preterm labor, the patient's fluids should be a. restricted to 1,000 to 1,500 mL per 24 hours b. restricted to 1,500 to 2,400 mL per 24 hours c. forced to 2,400 to 3,000 mL per 24 hours - B Pulmonary status should be monitored closely as patients receiving some tocolytics, such as magnesium sulfate and some beta-2 agonists (terbutaline), may develop tocolytic-inducted pulmonary edema; however, this is a fairly rare condition. 67 At 26 weeks' gestation, the fundal height is 31 cm, which may indicate a. macrosomia b. polyhydramnios c. uterine abnormality - A A fundal height more than 4 cm greater than the number of weeks of gestation is an indication of macrosomia, which is most common in women who are diabetic or severely obese, or who have gained an excessive amount of weight during pregnancy. Macrosomia is diagnosed with estimated fetal weight more than the 90th percentile for expected weight or more than 4500g. Because the fetus stretches the myometrium, the second stage of labor is often prolonged, and the mother is at risk for ruptured uterus. With vaginal delivery, the mother may have extensive lacerations or postpartum hemorrhage. The most effective relief of a spinal headache after spinal blockade is usually a. keeping flat for 6 to 12 hours b. analgesia c. blood patch to insertion site - C While recommendations are for the patient to lie flat for 6-12 hours after the blockade to prevent headache, there is little evidence that actually helps. With a blood patch, a small amount of the patient's blood is removed and then injected immediately (before coagulating) into the epidural space at the puncture site to seal leakage of spinal fluid, which is assumed to be the cause of the headache. The birthing method that encourages women to use specific movements called the "birth dance" to relieve discomfort is a. Kitzinger method b. Bradley method c. Lamaze method - A -Kitzinger: Encourage alternatives to usual hospital procedures, development of a birth plan, and the use of chest breathing, abdominal relaxation, touch relaxation, visualization, and the "birth dance" to relieve discomfort. -Bradley: Focuses on natural childbirth and education about woman's health and needs of the newborn. Woman and partner participate. 70 The fluid collects beneath the skin but above the periosteum, so it freely crosses suture lines, unlike cephalohematoma, which is a collection of blood between the periosteum and the skull. Caput succedaneum is common with prolonged labor because of the pressure of the head against the cervix and may be more pronounced with vacuum-assisted deliveries. If a neonate does not blink when a light is flashed in his or her eyes, this may indicate a. cerebral palsy b. a normal finding c. sedation - A The blinking reflex should be present at birth and remain throughout life. The assessment consists of flashing a light or aiming a puff of air at the neonate's eyes. The normal response is for the child to immediately blink, as this is a protective mechanism. If the blink reflex is absent or delayed, this may be an indication of brain damage, such as may occur with cerebral palsy, hydrocephalus, or some form of developmental delay. Further testing is indicated to determine the cause of the abnormal response. When a supine infant is placed in a radiant warmer for thermoregulation, the skin temperature probe may be placed a. in the mid-scapular region b. over the mediastinum c. over the liver - C The probe should not be placed over a bony area, such as the mediastinum, or over an area that has a large amount of brown adipose tissue, such as the midscapular regions of the back, the neck, and areas around the kidneys and adrenal glands. The probe should be placed carefully, ensuring good skin contact so that it accurately records temperature, as this will affect the temperature setting of the heater. Following delivery, the mother should be encouraged to urinate a. within 1 hour b. within 3 hours c. within 4 hours - A ....and should empty the bladder at least every 4-6 hours. Because of periurethral edema post delivery, dysuria is common and bladder retention may occur; catheterization should be avoided and should not be done more than twice in 24 hours 71 if possible. Warm water may be poured over the perineum to relax muscles and promote urination. Normal urinary volume per voiding is usually 300-400 mL. Afterpains may persist for a. 24 hours b. 2 to 3 days c. 7 days - B With the first pregnancy, the uterus often stays contracted after delivery, but with following pregnancies or when there are complications (hydramnios, clot retention), the uterus may alternate between contractions and relaxations, resulting in severe cramping afterpains that may persist for 2-3 days. Treatment with oxytocin or breastfeeding, which causes natural release of oxytocin, may also cause afterpains. Afterpains are usually treated with a mild analgesic, such as acetaminophen or ibuprofen. If a mother is Rh- and the father Rh+, the mother should receive Rho(D) immune globulin (RhoGAM) a. at 26 to 28 weeks' gestation and 72 hours after delivery b. 72 hours after delivery only c. at 32 weeks' gestation and 24 hours after delivery - A ...to prevent erythroblastosis fetalis. RhoGAM contains Rh+ antibodies, which agglutinate any fetal blood cells that pass into the maternal circulatory system, preventing the mother from developing antibodies tot he fetal cells. If antibodies form, they attack the fetus and sensitize the mother for future pregnancies. The trimester in which the ultrasound can first be used to examine the fetus for birth defects of the brain and spine is the a. first b. second c. third - A First: estimate gestational age (accuracy +/- 1 to 2 weeks), assess vaginal bleeding, assess for multiple fetuses, and assess for birth defects of brain/spine Second: estimate gestational age (accuracy +/- 2 weeks), assess size and position of placenta, fetus, and umbilical cord, assess for major birth defects (cardiovascular/neural tube) 72 Third: estimate gestational age (accuracy +/- 2 to 3 weeks), assess fetal viability, assess size and position of placenta, fetus, and umbilical cord, and estimate AFI According to NICHD terminology and definitions, a fetal baseline heart rate of 140 bpm would be considered a. bradycardia b. normal c. tachycardia - B Normal fetal baseline heart rate is 110-160 bpm. Bradycardia is heart rate below 110 bpm and tachycardia is above 160 bpm. A symmetrical deceleration with a gradually decreasing fetal heart rate and return to baseline over at least 30 seconds in response to uterine contractions with the deceleration nadir occurring at the peak of the contraction is a. a late deceleration b. an early deceleration c. a variable deceleration - B Late decelerations: similar parameters but the nadir of the deceleration occurs after the peak of the uterine contraction. Variable deceleration: sudden decrease in heart rate lasting less than 30 seconds that may or may not be associated with uterine contractions with the heart rate decreasing by at least 15 bpm for at least 15 seconds but less than 2 minutes. Prolonged decelerations: lasts at least 2 minutes but less than 10 minutes Upon initial assessment, a newborn is found to have a portion of the spinal cord protruding from his lower back. This is indicative of a. spina bifida b. hypospadias c. tetralogy of Fallot - A Is a severe neural tube defect and congenital anomaly in which the backbone and membranes around the spinal cord protrude through an incomplete closing in the lower back of the newborn. Upon birth, this sac should be closely protected from rupture or injury prior to surgery. 75 c. obtain specimens (skin, mucus) for culture and PCR assay 24 hours after delivery - C If the tests show that the neonate is positive for HSV, then the child should undergo a complete examination and treatment should begin with IV acyclovir as soon as possible. If, however, maternal herpes lesions are present during delivery in a woman with no history of HSV, then the infant should immediately begin treatment with IV acyclovir. A woman who has human papilloma virus (HPV) and genital warts should be advised that a. pregnancy should have be avoided as the infection may result in birth defects b. HPV is rarely transmitted to the infant during vaginal delivery c. cesarean will be required to prevent transmission to the infant - B ..., so infection is not a routine reason for a cesarean, but it may be advised if the genital warts are so large that they block the birth canal. In rare instances, the infant may develop HPV infection and warts in the mouth and throat (laryngeal papillomatosis). If a woman develops vaginal candidiasis during pregnancy, the treatment recommendation is a. vaginal cream or suppository, such as Monistat (miconazole) b. oral Diflucan (fluconazole) c. delay treatment until after delivery of infant - A Vaginal candidiasis is especially common during the second trimester because of hormonal changes, and may result in itching and watery, yeast-smelling discharge. Oral Diflucan (fluconazole) is not advised during pregnancy or lactation because of safety concerns. Untreated, the mother may pass the infection to the infant during delivery, resulting in oral candidiasis (thrush). A woman who develops appendicitis in the third trimester will often complain of pain in or near the a. LLQ b. RLQ c. RUQ - C Appendicitis may be misdiagnosed during pregnancy because the position of the appendix changes as the uterus enlarges, sometimes moving superiorly as much as 8 76 inches. While in non-pregnant woman, pain from appendicitis is typically felt in the RLQ, the pain is more likely to be felt in or near the RUQ as pregnancy advances. While surgery poses some risks, a ruptured appendix may result in the death of the mother and the fetus. Before flu season, a pregnant woman should a. receive injectable flu vaccine b. receive nasal spray flu vaccine c. avoid all forms of vaccine - A ...which helps protect both the mother and the fetus (and the infant after birth up to 6 months). However, the nasal spray vaccine should be avoided during pregnancy. Influenza may result in more severe forms of illness in a woman who is pregnant because of pregnancy-associated immune differences. Additionally, influenza poses risks to the fetus, sometime resulting in premature delivery. The pregnant woman should also avoid contact with those with influenza. When counseling an HIV/AIDS patient about breastfeeding, the mother should be advised that a. breastfeeding poses little risk to the infant b. breastfeeding should only be done if the mother's CD4 count is more than 1,000. c. breastfeeding should be avoided because of risk of transmission - C ...with risk at about 0.7% for each month of breastfeeding. Antiviral therapy should be continued throughout pregnancy as this decreases the risk of transmission to the fetus. Infants are most at risk from untreated HIV positive mothers, with transmission rates of about 30% with infection usually occurring during delivery Anemia of pregnancy is defined as hemoglobin of a. 11 g/dL (110 mmol/L) or less b. 12 g/dL (120 mmol/L) or less c. 14 g/dL (140 mmol/L) or less - A Less than 11 g/dL (first and third trimesters) or less than 10.5 g/dL in the second trimester, while anemia in a non-pregnant woman would be less than 12 g/dL. During pregnancy, the RBC mass increases, resulting in lower relative hemoglobin. Anemia of pregnancy increases the risk of maternal infection, pre-E, and hemorrhage after delivery, as well as increases rates of miscarriage, low birth weight, and stillbirth. 77 An over-the-counter drug that should be avoided during pregnancy is a. Benadryl (diphenhydramine) b. Tylenol (acetaminophen) c. Motrin (ibuprofen) - C ...and other NSAIDs because they may cause heart defects in the fetus. They especially pose a risk during the third trimester. Tylenol is generally safe to take during pregnancy for mild pain or fever, but aspirin should also be avoided because it can cause birth defects. Pregnant women who need an antihistamine may take Benadryl but should be aware it may cause drowsiness. Infants born to addicted mothers are likely to experience the least severe neonatal abstinence syndrome (NAS) if, during pregnancy, the mother received a. Suboxone (buprenorphine and naloxone) b. buprenorphine c. methadone - B ...rather than methadone. NAS symptoms tended to be milder, and infants required shorter hospitalizations to control withdrawal. Suboxone (buprenorphine and naloxone) is usually avoided during pregnancy because of the addition of naloxone. About a week after delivery of an infant, the mother's pulse often a. decreases b. increases c. remains the same - A 6-10 days. This is known as puerperal bradycardia and results from a combination of of decreased blood volume and strain on the heart and increased stroke volume. Pulse rates may range from 60-70 bpm. When tachycardia occurs, it is often an indication of excessive blood loss, but tachycardia may also result from the stress of prolonged labor. BP rates usually remain within normal limits but orthostatic hypotension may occur for the first few hours after delivery. Postpartum blues usually occur a. 24 hours or less after delivery with duration of 2 to 3 weeks b. 2 to 3 days after delivery with duration of 3 to 12 months c. 5 days or less after delivery with duration of 2 to 3 days - C Affect up to 80% of new mothers. Postpartum blues, usually occurs 5 days or less after delivery with a duration of 2 to 3 days. However, it may persist over a week in 80 The most common source of Escherichia coli infection in the neonate is a. hands of caregivers b. contaminated equipment c. maternal gastrointestinal tract - C ...with the infection usually obtained during vaginal delivery. E. coli infections in the neonate may be severe and can include urinary tract infections, bacteremia, sepsis, and meningitis. Preterm infants or those with impaired immune systems are especially at risk during or after delivery. Symptoms may vary widely depending on the extent of the infection but often include diarrhea, irritability, fever, and poor feeding. The probable gestational age of an infant born with dry, wrinkled, peeling skin, no vernix, and loss of subcutaneous fat is a. 24 to 26 weeks b. 35 to 40 weeks c. 42 to 44 weeks - C -24 to 26 weeks: translucent, red, many visible blood vessels, scant vernix -35 to 40 weeks: deep cracks, no visible blood vessels, thick vernix -42 to 44 weeks: dry, wrinkled, peeling skin, no vernix, loss of subcutaneous fat If the results of one study are replicated with additional studies, the initial study is said to have a. reliability b. validity c. usability - A ....especially using different methods or tools and different populations, the initial study is said to have reliability. Validity means that the study was successful in measuring that which was intended. External validity means that the study results are generalizable to other populations. Usability refers to the tools used in a study and the degree to which researchers are able to understand and use them properly. A pregnant woman with cervical funneling is at risk for a. hemorrhage b. miscarriage/preterm delivery c. prolonged labor - B 81 risk for cervical incompetence, which means that the muscles of the cervix are weak and the pressure of the growing fetus may produce early effacement and dilation before contractions begin, resulting in miscarriage or preterm delivery during the second and third trimester. A normal cervix is 30 mm long; cervical incompetence means the cervix is less than 25 mm long at 24 weeks or less of gestation. The shorter the cervix, the greater the risk of preterm birth. At 4 weeks gestation, two beta hCG values taken 48 hours apart show decreasing values. This suggests a. normal pregnancy b. miscarriage/ectopic pregnancy c. inaccurate calculation of inception - B Beta hCG is produced by the trophoblast or placenta and accurately indicates the presence of pregnancy. For the first 10 days of pregnancy, the levels double every 2 days and then continue to increase until peaking at 60-90 days after conception, so a stable to falling level indicates that the pregnancy is not progressing. A neonate's umbilical cord blood values were pH 7.16, pO2 18 mmHg, and pCO2 55 mmHg, with base excess of 11 mEq/L, indicating a. normal values b. respiratory acidosis c. metabolic acidosis - C -Respiratory acidosis: pH < 7.25, pO2 varies, pCO2 > 50 mmHg, Base excess < 10 mEq/L -Metabolic acidosis: pH < 7.25, pO2 < 20 mmHg, pCO2 44-55 mmHg, base excess > 10 mEq/L If fetal scalp blood sampling is done because of an unusual fetal heart rate pattern, a pH of 7.2 indicates a. the need for immediate delivery b. a normal value c. the need for repeat sampling in 20 minutes - A ...usually either with forceps delivery if criteria are met or with cesarean. A normal fetal pH is 7.25 or greater. If the level is 7.21-7.24, repeat fetal scalp blood sampling may be done every 20 minutes until there is a changes in the FHR pattern for better or worse, indicating the need for delivery 82 Repeated variable decelerations of fetal heart rate during labor suggest a. normal variations b. umbilical cord occlusion c. uteroplacental insufficiency - B The fetus may roll on the cord or the cord may be around the neck, resulting in occlusion during uterine contractions Repeated variable decelerations may also indicate a short cord or occult prolapse of the cord. If the variable decelerations occur occasionally without pattern, they are usually not of concern, but if they are repeated and worsen as labor progresses, the fetus is at risk. If the variable decelerations are in response to rupturing the membranes, changing the mother's position may alleviate the decelerations. The latent phase of the first stage of labor for a nullipara usually lasts about a. 10 hours b. 8.5 hours c. 5.3 hours - B ...(5.3 hours for a multipara) and the cervix dilates up to 3 cm. The frequency of contractions varies from every 3 to every 30 minutes with contractions lasting 20-40 seconds. Contractions usually range from mild to moderate. Most patients can manage the discomfort during this phase but they may feel increasing anxiety, especially nulliparas. During the second stage of labor, the patient feels a strong urge to bear down because of a. pressure on the sacral and obturator nerves b. pressure on the femoral nerves c. pressure on the perineum, rectum, and anus - A ...as the fetus descends the birth canal. The second stage usually lasts for about 2 hours for the nullipara and 15 minutes for the multipara with contractions occurring every 1.5-2 minutes and persisting for 60-90 seconds. As the fetus descends and the head crowns, the patient feels increasingly intense pain and pressure on the perineum. The purpose of a birth plan is to a. tell the expectant mother what to expect during labor and delivery b. provide a checklist for the physician and midwife 85 The purpose of the modified Ritgen maneuver during delivery is to a. prevent perineal lacerations b. speed delivery of the head c. rotate the fetus the correct position - A (hands on). as the head is delivered, the physician or midwife applies upward pressure from the coccygeal region, which causes the fetal head to extend during birth, protecting the perineal musculature. A different approach (hands off) is also sometimes used. With this approach, the physician or midwife does not touch the perineum or assist with delivery of shoulders or body but applies light pressure to the fetal head if necessary to prevent rapid expulsion. Criteria for outlet forceps-assisted birth include a. the fetal sagittal suture is more than 45 degrees from midline b. the fetal skull is above the pelvic floor c. the scalp is visible between contractions without separating labia - C Additional criteria include (2) the perineum bulging because the fetal skull has reached the pelvic floor, (3) the fetal sagittal sutures 45 degrees or less from the midline indicating the head moving from extension to external rotation. Low forceps-assisted birth may occur if the fetal skull is at station +2 or lower but above the pelvic floor. Midforceps-assisted birth may occur if the fetal head is engaged but leading edge is above station +2 The labor management approach that is most successful in lowering rates of cesarean births is a. ambulation during labor b. one-on-one support c. frequent maternal position changes - B ...and this can take a variety of forms: nurse, husband/partner, midwife, or doula. Someone should stay with the pregnant woman during labor, providing support and encouragement and assisting with comfort measures. Other interventions include encouraging the patient to ambulate during labor, make frequent changes of position, practice methods of relaxation, take adequate fluid and nutrition, and use various methods of nonpharmacologic pain relief. 86 The primary advantage of a combined spinal epidural (CSE) over a regular epidural is a. ability to ambulate b. better pain control c. fewer fetal effects - A With a regular epidural, the mother is typically confined to bed but advised to turn from side to side at least every hour. With the CSE, an opioid and/or anesthetic is injected into the intrathecal area and then the needle is withdrawn into the epidural space and the catheter threaded into that area. Epidural anesthesia can be administered when the patient feels the initial injection is no longer adequate. The most common complication after spinal blockade is a. hypertension b. hypotension c. confusion - B ...because of blockade of sympathetic fibers. maternal hypotension increases the risk of fetal hypoxia, so vital signs must be monitored frequently after spinal blockade. Preventive measures include prehydrating with IV fluids (500-1000 mL non- dextrose) and positioning so that the uterus is displaced to the left. If hypotension occurs, the patient should be placed in left lateral, head lowered position, and rapidly infusing with IV fluids. If it is unclear whether the membranes have ruptured when a patient is admitted in labor, the initial vaginal exam should be a. digital b. sterile speculum c. delayed - B ...to determine if spontaneous rupture has occurred. Additionally, if there is bleeding, a speculum allows visualization to help identify the source, while a digital exam may disrupt a placenta previa. If a digital exam is indicated, it should be done using aseptic technique after labor has ensued even if the membranes have ruptured. If fragments of the placenta remain in the uterus after placental expulsion, this often results in a. infection 87 b. hypertonic uterus c. hemorrhage - C ...because fragments prevent the uterus from completely contracting and constricting vessels. The placenta should be carefully examined after expulsion to determine if it is intact or if fragments are missing. A manual exploration of the uterus may be indicated if fragments remain in order to separate the fragments from the uterus while supporting the fundus externally with the other hand. An obstetric laceration that extends through the rectal sphincter but not into the rectal mucosa would be classified as a. second degree b. third degree c. fourth degree - B First: involves vaginal mucosa or skin of perineum but not the underlying tissue Second: involves underlying tissue but the tear does not invade the rectal sphincter or rectal mucosa Third: extends through the rectal sphincter but not further into the rectal mucosa Fourth: extends through the rectal sphincter and into the rectal mucosa A pudendal nerve block a. relieves pain in the lower vagina and perineum b. relieves the pain of uterine contractions c. relieves pain in the lower back - A ...but it must be administered 10-20 minutes prior to the need for perineal anesthesia. The nerve block provides effective relief of pain in the second stage of labor, episiotomy, and birth. It does not relieve pain associated with uterine contractions or back pain, and it has no effect on the thermodynamics of the mother or fetus and does not affect the FHR. The pudendal nerve block does result in lessened or absent bearing down reflex. If a patient is to receive general anesthesia for emergency cesarean, the patient should first be administered a. liquid antacid 90 The vanishing twin syndrome results from miscarriage of one fetus with the tissue absorbed by the mother or the other fetus and occurs in up to 30% of twin pregnancies. The patient may or may not have indications of miscarriage (cramping, bleeding) when one twin dies. If the vanishing twin occurs in the second or third trimester, the pregnancy is considered high risk, and the remaining twin is at risk for cerebral palsy. A 32 week pregnant patient with sudden onset of severe lower abdominal pain and tenderness, vaginal bleeding, tachycardia, hypotension, and fetal bradycardia probably indicates a. placenta previa b. uterine rupture c. abruptio placentae - C ...as these are typical symptoms although pain and tenderness are absent in some patients. About 70% with abruptio placentae present with vaginal bleeding. Pain may be localized or diffuse. In some cases, blood accumulates between the placenta and the myometrium (Couvelaire uterus), resulting in ecchymosis, discoloration of the uterus,and loss of contractility. Hypotension with a positive Cullen sign (ecchymosis about umbilicus) and shoulder pain may indicate a. ruptured uterus b. ruptured ectopic pregnancy c. spontaneous abortion - B The hypotension occurs because of blood loss, and blood in the perineal cavity causes irritation of the diaphragm and referred pain to the shoulder area as well as the ecchymosis about the umbilicus. While an unruptured ectopic pregnancy often causes pain, the pain increases with rupture and may vary in intensity and site, with some patients complaining of pain in the lower abdomen and some with unilateral or generalized abdominal pain Preterm labor is defined as onset of labor before a. 35 weeks b. 37 weeks c. 39 weeks - B 91 ...with cervical change and uterine contractions during weeks 20-36. Most infant deaths (more than 75%) associated with preterm labor and birth occur in infants who are fewer than 32 weeks gestation. Risk factors for preterm labor include maternal age younger than 17 or older than 35 years, non-white race, lower economic status, and lower educational status. Patients with previous preterm labor or birth or who have undergone second trimester abortions or had stillbirths are also at increased risk. The most significant risk factor for uterine rupture is a. macrosomia b. multiple gestation c. previous cesarean - C Uterine rupture extends through the wall of the uterus and the visceral peritoneum, resulting in extensive bleeding and can include expulsion of the fetus and placenta into the abdominal cavity. Treatment includes immediate cesarean delivery and usually requires hysterectomy. In some cases, instead of full rupture, dehiscence occurs along the previous incisional line, but dehiscence usually does not involve extensive bleeding and does not breech the visceral peritoneum, so the fetus and placenta remain inside the uterus. If meconium-stained amniotic fluid is observed during delivery of an infant, the initial response should be to a. suction the infant before his/her first breath b. evaluate the infant's respiratory status c. suction the infant after he/she begins breathing - A ..., before the shoulders and body are delivered if possible, to prevent aspiration of meconium and meconium aspiration syndrome (MAS). The severity of symptoms depends on the amount of meconium aspirated. Thick meconium poses more or a risk than think meconium. If the neonate aspirated meconium, the child may exhibit respiratory depression on delivery, requiring resuscitation. In a neonate, Klumpke paralysis is associated with injury to the a. median and ulnar nerves in the arm b. lower nerves of the brachial plexus c. upper roots of the brachial plexus - B It affects the hand while Erb (Erb-Duchenne) palsy, caused by injury to the upper roots of the brachial plexus, causes paralysis of the upper arm and forearm so that the 92 arm hangs limply with the forearm extended and internally rotated. Finger function is usually not impaired. Injury to the brachial plexus is most common with macrosomia and breech or difficult deliveries. Low birth weight is defined as a. 1500 g or less b. 2000 g or less c. 2500 g or less - C It is sometimes used instead of the term preterm birth because weeks of gestation are not always easy to identify, and preterm birth considers only duration of gestation and not the weight of the child. Infants who have low birth weight may be preterm as well, or the low birth weight may be attributable to other factors, such as IUGR, PIH, or maternal malnutrition With precipitous labor, the entire process of labor and delivery occurs within a. 2 hours b. 3 hours c. 4 hours - B ...with the primigravida dilating 5 cm or more per hour and the multipara up to 10 cm per hour. Precipitous labor is most common in women older than 35 years. It is usually associated with low resistance in soft tissues so that the cervix dilates and effaces rapidly, and with unusually strong uterine contractions. Because the birth is so rapid, it may be unattended or occur on the way to the hospital. The three most common factors associated with labor abnormalities are (1) the fetus, (2) the pelvic size and shape, and (3) the a. uterine contractility b. age of the mother c. weeks of gestation - A -Fetus: size (such as macrosomia), lie and presentation may slow labor or interfere with contractions and fetal descent - Pelvic size and shape: a small or narrow pelvis or abnormally shaped pelvis may prevent the fetus from engaging and descending