Which of the following best describes preterm labor?
-
Solution
Labor that begins after 20 weeks gestation and before 37 weeks gestation
Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.
When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?
-
Solution
Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available.
Option A: Allowing the mother’s support person to remain with her as much as possible is an important concept, although doing so depends on many variables.
Option B: Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility.
Option D: The nurse is responsible for reinforcing the explanations about the surgery expected outcome, and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome, and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.
Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?
-
Solution
Tetanic contractions prolonged to more than 90 seconds
Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture.
Option A: Weak contractions would not occur.
Options C and D: Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation.
Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
-
Solution
Abruptio placentae
Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage.
Option A: Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy.
Option B: Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium.
Option C: Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.
Which of the following would the nurse assess in a client experiencing abruptio placenta?
-
Solution
Concealed or external dark red bleeding
A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to board-like, and the fetal presenting part may be engaged.
Options A, C, and D: Bright red, painless vaginal bleeding, a palpable fetal outline, and a soft non-tender abdomen are manifestations of placenta previa.
Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
-
Solution
Multiple gestation
Multiple gestation is one of the predisposing factors that may cause placenta previa.
Options B, C, and D: Uterine anomalies abdominal trauma and renal or vascular disease may predispose a client to abruptio placentae.
In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy test?
-
Solution
Missed
In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness.
Option A: A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation.
Option B: An imminent-abortion indicated by bleeding and pain along with an effaced cervix.
Option D: An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.
Which of the following would the nurse identify as a classic sign of PIH?
-
Solution
Edema of the hands and face
Edema of the hands and face is a classic sign of PIH.
Option A: Many healthy pregnant woman experience foot and ankle edema.
Option C: A weight gain of 2 lb or more per week indicates a problem.
Option D: Early morning headache is not a classic sign of PIH.
Which of the following statements best describes hyperemesis gravidarum?
-
Solution
Severe nausea and vomiting leading to the electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to the electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
Option A: Hyperemesis is not a form of anemia.
Option C: Loss of appetite may occur secondary to nausea and vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus.
Option D: Diarrhea does not occur with hyperemesis.
Which of the following describes the Babinski reflex?
-
Solution
The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.
With the Babinski reflex, the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of the foot is stroked upward from the heel and across the ball of the foot.
Option B: With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise.
Option C: With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched.
Option D: With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.