G2A SUMMER 2015

1. Which one do you like?

Option 1

Option 2

Option 3

Option 4

2. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

Activity limited to bed rest

Platelet infusion

Immediate cesarean delivery

Labor induction with oxytocin

3. Normal lochial findings in the first 24 hours post-delivery include:

Bright red blood

Large clots or tissue fragments

A foul odor

The complete absence of lochia

4. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

Wearing a supportive brassiere with nipple shields

Breast-feeding the neonate at frequent intervals

Decreasing fluid intake for the first 24 to 48 hours

Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.

Explanation

Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.

5. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

Endometritis

Endometriosis

Salpingitis

Pelvic thrombophlebitis

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes.

Explanation

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes.

6. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond?

“Yes, it produces no adverse effect.”

“No, it can initiate premature uterine contractions.”

“No, it can promote sodium retention.”

“No, it can lead to increased absorption of fat-soluble vitamins.”

7. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Notify the neonate’s pediatrician immediately

Check the diaper and circumcision again in 30 minutes

Secure the diaper tightly to apply pressure on the site

Apply gently pressure to the site with a sterile gauze pad

If bleeding occurs after circumcision, the nurse should first apply gently pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

Explanation

If bleeding occurs after circumcision, the nurse should first apply gently pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

8. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?

Active phase

Latent phase

Expulsive phase

Transitional phase

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active phase extends form 4 to 7 cm; it is moderate for the patient. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

Explanation

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active phase extends form 4 to 7 cm; it is moderate for the patient. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

9. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

Decreased peristalsis

Increase heart rate

Dry mucous membranes

Nausea and Vomiting

Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

Explanation

Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

10. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?

Active phase

Complete phase

Latent phase

Transitional phase

The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

Explanation

The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

11. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient?

Knowledge deficit

Fluid volume deficit

Anticipatory grieving

Pain

If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

Explanation

If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

12. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

The membranes must rupture

The fetus must be at 0 station

The cervix must be dilated fully

The patient must receive anesthesia

13. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:

Apply warm compresses to her nipples just before feedings

Lubricate her nipples with expressed milk before feeding

Dry her nipples with a soft towel after feedings

Apply soap directly to her nipples, and then rinse

14. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?

Low room humidity

Cools incubator walls

Cool room temperature

15. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration?

Oxytoxin causes water intoxication

Oxytocin causes excessive thirst

Oxytoxin is toxic to the kidneys

Oxytoxin has a diuretic effect

The nurse should monitor fluid intake and output because prolonged oxytoxin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results form the work of labor and limited oral fluid intake—not oxytoxin. Oxytoxin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

Explanation

The nurse should monitor fluid intake and output because prolonged oxytoxin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results form the work of labor and limited oral fluid intake—not oxytoxin. Oxytoxin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

16. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

Back

Abdomen

Fundus

Perineum

G2a Summer 2015