Maternal & Child Practice Exam (Intrapartum)

1. A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted?

1. The client begins to expel clear vaginal fluid
2. The contractions are regular
3. The membranes have ruptured
4. The cervix is dilated completely

2. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to:

1. Place the mother in the supine position
2. Document the findings and continue to monitor the fetal patterns
3. Administer oxygen via face mask
4. Increase the rate of pitocin IV infusion

3. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician?

1. Fetal heart rate of 180 beats per minute
2. White blood cell count of 12,000
3. Maternal pulse rate of 85 beats per minute
4. Hemoglobin of 11.0 g/dL

4.  A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the:

1. Trendelenburg’s position with the legs in stirrups
2. Semi-Fowler position with a pillow under the knees
3. Prone position with the legs separated and elevated
4. Supine position with a wedge under the right hip

5. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:

1. Noting if the heart rate is greater than 140 BPM
2. Placing the diaphragm of the Doppler on the mother abdomen
3. Performing Leopold’s maneuvers first to determine the location of the fetal heart
4. Palpating the maternal radial pulse while listening to the fetal heart rate

6. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

1. Three contractions occurring within a 10-minute period
2. A fetal heart rate of 90 beats per minute
3. Adequate resting tone of the uterus palpated between contractions
4. Increased urinary output

7. A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion?

1. Placing the client on complete bed rest
2. Continuous electronic fetal monitoring
3. An IV infusion of antibiotics
4. Placing a code cart at the client’s bedside

8. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?

1. Encourage the client’s coach to continue to encourage breathing exercises
2. Encourage the client to continue pushing with each contraction
3. Continue monitoring the fetal heart rate
4. Notify the physician or nurse midwife

9. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?

1. Document the findings and tell the mother that the monitor indicates fetal well-being
2. Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen.
3. Notify the physician or nurse midwife of the findings.
4. Reposition the mother and check the monitor for changes in the fetal tracing

10. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the monitor, the initial nursing assessment is which of the following?

1. Identifying the types of accelerations
2. Assessing the baseline fetal heart rate
3. Determining the frequency of the contractions
4. Determining the intensity of the contractions

11. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is:

1. 1 cm above the ischial spine
2. 1 fingerbreadth below the symphysis pubis
3. 1 inch below the coccyx
4. 1 inch below the iliac crest

12. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client’s hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following?

1. A loud mouth
2. Low self-esteem
3. Hemorrhage
4. Postpartum infections

13. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:

1. Hematoma
2. Placenta previa
3. Uterine atony
4. Placental separation

14. A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have:

1. Less pressure on her cervix
2. Increased efficiency of contractions
3. Decreased number of contractions
4. The need for increased maternal blood pressure monitoring

15. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?

1. Early decelerations
2. Variable decelerations
3. Late decelerations
4. Short-term variability

16. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is:

1. A form of biofeedback to enhance bearing down efforts during delivery
2. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus
3. The application of pressure to the sacrum to relieve a backache
4. Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

17. A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as:

1. Exhaustion
2. Fear of losing control
3. Involuntary grunting
4. Valsalva’s maneuver

18. A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.

1. Stop of Pitocin infusion
2. Perform a vaginal examination
3. Reposition the client
4. Check the client’s blood pressure and heart rate
5. Administer oxygen by face mask at 8 to 10 L/min

19. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician’s orders and would expect to note which of the following prescribed treatments for this condition?

1. Medication that will provide sedation
2. Increased hydration
3. Oxytocin (Pitocin) infusion
4. Administration of a tocolytic medication

20. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to:

1. Monitor the Pitocin infusion closely
2. Provide pain relief measures
3. Prepare the client for an amniotomy
4. Promote ambulation every 30 minutes

21. A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority?

1. Keeping the significant other informed of the progress of the labor
2. Providing comfort measures
3. Monitoring fetal heart rate
4. Changing the client’s position frequently

22. A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor:

1. Over the fetus that is most anterior to the mother’s abdomen
2. Over the fetus that is most posterior to the mother’s abdomen
3. So that each fetal heart rate is monitored separately
4. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

23. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

1. Disseminated intravascular coagulation
2. Chronic hypertension
3. Infection
4. Hemorrhage

24. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

1. The umbilical cord shortens in length and changes in color
2. A soft and boggy uterus
3. Maternal complaints of severe uterine cramping
4. Changes in the shape of the uterus

25. A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?

1. Place the client in Trendelenburg’s position
2. Call the delivery room to notify the staff that the client will be transported immediately
3. Gently push the cord into the vagina
4. Find the closest telephone and stat page the physician

26. A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

1. Swelling of the calf in one leg
2. Prolonged clotting times
3. Decreased platelet count
4. Petechiae, oozing from injection sites, and hematuria

27. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

1. Absence of abdominal pain
2. A soft abdomen
3. Uterine tenderness/pain
4. Painless, bright red vaginal bleeding

28. A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s orders and would question which order?

1. Prepare the client for an ultrasound
2. Obtain equipment for external electronic fetal heart monitoring
3. Obtain equipment for a manual pelvic examination
4. Prepare to draw a Hgb and Hct blood sample

29. An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for:

1. Complete bed rest for the remainder of the pregnancy
2. Delivery of the fetus
3. Strict monitoring of intake and output
4. The need for weekly monitoring of coagulation studies until the time of delivery

30. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred?

1. Hypotonic contractions
2. Forceps delivery
3. Schultz delivery
4. Weak bearing down efforts

31. A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be:

1. Auscultating the fetal heart
2. Taking an obstetric history
3. Asking the client when she last ate
4. Ascertaining whether the membranes were ruptured

32. A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is:

1. Not yet engaged
2. Entering the pelvic inlet
3. Below the ischial spines
4. Visible at the vaginal opening

33. After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:

1. Above the umbilicus at the midline
2. Above the umbilicus on the left side
3. Below the umbilicus on the right side
4. Below the umbilicus near the left groin

34. The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:

1. Until the time it is completely over
2. To the end of a second contraction
3. To the beginning of the next contraction
4. Until the time that the uterus becomes very firm

35. The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:

1. Clear and dark amber in color
2. Milky, greenish yellow, containing shreds of mucus
3. Clear, almost colorless, and containing little white specks
4. Cloudy, greenish-yellow, and containing little white specks

36. At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:

1. Discontinue the catheter, if the reading is not above 80%
2. Discontinue the catheter, if the reading does not go below 30%
3. Advance the catheter until the reading is above 90% and continue monitoring
4. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

37. When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:

1. Stop the oxytocin infusion
2. Change the client’s position
3. Prepare for immediate delivery
4. Take the client’s blood pressure

38. When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:

1. An acceleration
2. An early elevation
3. A sonographic motion
4. A tachycardic heart rate

39. A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:

1. Breech
2. Transverse
3. Occiput anterior
4. Occiput posterior

40. The breathing technique that the mother should be instructed to use as the fetus’ head is crowning is:

1. Blowing
2. Slow chest
3. Shallow
4. Accelerated-decelerated

41. During the period of induction of labor, a client should be observed carefully for signs of:

1. Severe pain
2. Uterine tetany
3. Hypoglycemia
4. Umbilical cord prolapse

42. A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning, the client is bearing down, and the birth appears imminent. The nurse should:

1. Transfer her immediately by stretcher to the birthing unit
2. Tell her to breathe through her mouth and not to bear down
3. Instruct the client to pant during contractions and to breathe through her mouth
4. Support the perineum with the hand to prevent tearing and tell the client to pant

43. A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she:

1. Will not feel the episiotomy
2. May lose bladder sensation
3. May lose the ability to push
4. Will no longer feel contractions

44. Which of the following observations indicates fetal distress?

1. Fetal scalp pH of 7.14
2. Fetal heart rate of 144 beats/minute
3. Acceleration of fetal heart rate with contractions
4. Presence of long term variability

45. Which of the following fetal positions is most favorable for birth?

1. Vertex presentation
2. Transverse lie
3. Frank breech presentation
4. Posterior position of the fetal head

46.  A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor?

1. Gender of the fetus
2. Fetal position
3. Labor progress
4. Oxygenation

47. A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?

1. Preparatory phase
2. Latent phase
3. Active phase
4. Transition phase

48. A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?

1. Let the client get up to use the potty
2. Allow the client to use a bedpan
3. Perform a pelvic examination
4. Check the fetal heart rate

49. Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?

1. Contractions, passageway, placental position and function, pattern of care
2. Contractions, maternal response, placental position, psychological response
3. Passageway, contractions, placental position and function, psychological response
4. Passageway, placental position and function, paternal response, psychological response

50. Fetal presentation refers to which of the following descriptions?

1. Fetal body part that enters the maternal pelvis first
2. Relationship of the presenting part to the maternal pelvis
3. Relationship of the long axis of the fetus to the long axis of the mother
4. A classification according to the fetal part

51. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?

1. Hysteria compounded by the flu
2. Placental abruption
3. Uterine rupture
4. Dysfunctional labor

52. Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data?

1. Fetal presenting part is 1 cm above the ischial spines
2. Effacement is 4 cm from completion
3. Dilation is 50% completed
4. Fetus has achieved passage through the ischial spines

53. Which of the following findings meets the criteria of a reassuring FHR pattern?

1. FHR does not change as a result of fetal activity
2. Average baseline rate ranges between 100 – 140 BPM
3. Mild late deceleration patterns occur with some contractions
4. Variability averages between 6 – 10 BPM

54. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin.  The woman is in a side-lying position, and her vital signs are stable and fall within a normal range.  Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:

1. Change the woman’s position
2. Stop the Pitocin
3. Elevate the woman’s legs
4. Administer oxygen via a tight mask at 8 to 10 liters/minute

55. The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be:

1. Severe postpartum headache
2. Limited perception of bladder fullness
3. Increase in respiratory rate
4. Hypotension

56. Perineal care is an important infection control measure.  When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

1. Uses soap and warm water to wash the vulva and perineum
2. Washes from symphysis pubis back to episiotomy
3. Changes her perineal pad every 2 – 3 hours
4. Uses the peribottle to rinse upward into her vagina

57. Which measure would be least effective in preventing postpartum hemorrhage?

1. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered
2. Encourage the woman to void every 2 hours
3. Massage the fundus every hour for the first 24 hours following birth
4. Teach the woman the importance of rest and nutrition to enhance healing

58. When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:

1. Express a strong need to review events and her behavior during the process of labor and birth
2. Exhibit a reduced attention span, limiting readiness to learn
3. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn
4. Have reestablished her role as a spouse/partner

59. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep.  The nurse should:

1. Tell the woman she can rest after she feeds her baby
2. Recognize this as a behavior of the taking-hold stage
3. Record the behavior as ineffective maternal-newborn attachment
4. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

60. Parents can facilitate the adjustment of their other children to a new baby by:

1. Having the children choose or make a gift to give to the new baby upon its arrival home
2. Emphasizing activities that keep the new baby and other children together
3. Having the mother carry the new baby into the home so she can show the other children the new baby
4. Reducing stress on other children by limiting their involvement in the care of the new baby

Answers and Rationales

1. Answer: D. The cervix is dilated completely. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.
2. Answer: C. Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
3. Answer: A. Fetal heart rate of 180 beats per minute. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.
4. Answer: D. Supine position with a wedge under the right hip. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus.
5. Answer: D. Palpating the maternal radial pulse while listening to the fetal heart rate. The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold’s maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.
6. Answer: B. A fetal heart rate of 90 beats per minute. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.
7. Answer: B. Continuous electronic fetal monitoring. Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.
8. Answer: D. Notify the physician or nurse midwife. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse midwife needs to be notified.
9. Answer: A. Document the findings and tell the mother that the monitor indicates fetal well-being.  Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.
10. Answer: B. Assessing the baseline fetal heart rate. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Identifying the types of accelerations and determining the frequency of the contractions are important to assess, but not as the first priority.
11. Answer: A. 1 cm above the ischial spine. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.
12. Answer: D. Postpartum infections. Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage.
13. Answer:  D. Placental separation. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
14. Answer: B. Increased efficiency of contractions. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
15. Answer:  B. Variable decelerations. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
16. Answer:  B. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.
17. Answer: B. Fear of losing control. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor.
18. Answer: A, D, B. E, C. If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord.
19. Answer: C. Oxytocin (Pitocin) infusion. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.
20. Answer: B. Provide pain relief measures. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.
21. Answer:  C. Monitoring fetal heart rate. The priority is to monitor the fetal heart rate.
22. Answer: C. So that each fetal heart rate is monitored separately. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.
23. Answer: D. Hemorrhage. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
24. Answer: D. Changes in the shape of the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping.
25. Answer: A. Place the client in Trendelenburg’s position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
26. Answer: A. Swelling of the calf in one leg. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.
27. Answer: C. Uterine tenderness/pain. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding.
28. Answer: C. Obtain equipment for a manual pelvic examination. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia.
29. Answer: B. Delivery of the fetus. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.
30. Answer: B. Forceps delivery. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.
31. Answer: A. Auscultating the fetal heart. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.
32. Answer: C. Below the ischial spines. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
33. Answer: C. Below the umbilicus on the right side. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
34. Answer: C. To the beginning of the next contraction.  This is the way to determine the frequency of the contractions
35. Answer: C. Clear, almost colorless, and containing little white specks.  By 36 weeks’ gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
36. Answer: D. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.
37. Answer: B. Change the client’s position. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.
38. Answer: A. An acceleration. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.
39. Answer: D. Occiput posterior. A persistent occiput-posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.
40. Answer: A. Blowing. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.
41. Answer: B. Uterine tetany. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
42. Answer: D. Support the perineum with the hand to prevent tearing and tell the client to pant. Gentle pressure is applied to the baby’s head as it emerges so it is not born too rapidly. The head is never held back, and it should be supported as it emerges so there will be no vaginal lacerations. It is impossible to push and pant at the same time.
43. Answer: A. Will not feel the episiotomy. A pudendal block provides anesthesia to the perineum.
44. Answer: A. Fetal scalp pH of 7.14. A fetal scalp pH below 7.25 indicates acidosis and fetal hypoxia.
45. Answer: A. Vertex presentation. Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie is an unacceptable fetal position for vaginal birth and requires a C-section. Frank breech presentation, in which the buttocks present first, can be a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis.
46. Answer: D. Oxygenation. Oxygenation of the fetus may be indirectly assessed through fetal monitoring by closely examining the fetal heart rate strip. Accelerations in the fetal heart rate strip indicate good oxygenation, while decelerations in the fetal heart rate sometimes indicate poor fetal oxygenation.
47. Answer: C. Active phase. Cervical dilation occurs more rapidly during the active phase than any of the previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7 cm. The preparatory, or latent, phase begins with the onset of regular uterine contractions and ends when rapid cervical dilation begins. Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.
48. Answer: C. Perform a pelvic examination.  A complaint of rectal pressure usually indicates a low presenting fetal part, signaling imminent delivery. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part.
49. Answer: C. Passageway, contractions, placental position and function, psychological response. The five essential factors (5 P’s) are passenger (fetus), passageway (pelvis), powers (contractions), placental position and function, and psyche (psychological response of the mother).
50. Answer: A. Fetal body part that enters the maternal pelvis first. Presentation is the fetal body part that enters the pelvis first; it’s classified by the presenting part; the three main presentations are cephalic/occipital, breech, and shoulder. The relationship of the presenting fetal part to the maternal pelvis refers to fetal position. The relationship of the long axis to the fetus to the long axis of the mother refers to fetal lie; the three possible lies are longitudinal, transverse, and oblique.
51. Answer: C. Uterine rupture. Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. With placental abruption, the client typically complains of vaginal bleeding and constant abdominal pain.
52. Answer: A. Fetal presenting part is 1 cm above the ischial spines. Station of – 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet.  A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged.  Passage through the ischial spines with internal rotation would be indicated by a plus station, such as + 1.  Progress of effacement is referred to by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10 cm indicating full dilation.
53. Answer: D. Variability averages between 6 – 10 BPM. Variability indicates a well oxygenated fetus with a functioning autonomic nervous system. FHR should accelerate with fetal movement.  Baseline range for the FHR is 120 to 160 beats per minute.  Late deceleration patterns are never reassuring, though early and mild variable decelerations are expected, reassuring findings.
54. Answer: B. Stop the Pitocin. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic which stimulates the uterus to contract. The woman is already in an appropriate position for uteroplacental perfusion. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.
55. Answer: D. Hypotension. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion.  The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.  Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia; 2 is an effect of epidural anesthesia but is not the most harmful.  Respiratory depression is a potentially serious complication.
56. Answer: D. Uses the peribottle to rinse upward into her vagina. Responses A, B, and C are all appropriate measures. The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.
57. Answer: C. Massage the fundus every hour for the first 24 hours following birth. The fundus should be massaged only when boggy or soft.  Massaging a firm fundus could cause it to relax.  Responses A, B, and D are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.
58. Answer: C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response C. This stage lasts for as long as 4 to 5 weeks after birth. Responses A and B are characteristic of the taking-in stage, which lasts for the first few days after birth. Response D reflects the letting-go stage, which indicates that psychosocial recovery is complete.
59. Answer: D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. Response A does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage.  The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists.  Mothers need to reestablish their own well-being in order to effectively care for their baby.
60. Answer: A. Having the children choose or make a gift to give to the new baby upon its arrival home. Special time should be set aside just for the other children without interruption from the newborn.  Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children.  Children should be actively involved in the care of the baby according to their ability without overwhelming them.