Correct answer: D. Blue.

If the client’s membranes have ruptured, the nitrazine paper will turn blue, an alkaline reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The definitive test for rupture of membranes is fern testing, where amniotic fluid is allowed to dry on a slide and then viewed under a microscope. Dried amniotic fluid will form a fern pattern. No other fluid forms this type of pattern.

Correct answer: D. Temperature.

Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client’s temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.

Correct answer: C. Intravenous penicillin.

Because group B streptococcus is a gram-positive bacterium, the primary health care provider probably will prescribe intravenous penicillin to treat the mother’s infection and prevent fetal infection. Gentamicin sulfate, which acts on gram-negative bacteria, would be inappropriate. Administering a corticosteroid, such as betamethasone, is inappropriate because the premature rupture of the membranes enhances fetal lung maturity. The lack of amniotic fluid causes early maturation of lung tissue. Cefaclor, which is available only in the oral form, is used for upper and lower respiratory tract infections and urinary tract infections by gram-negative staphylococci.

Correct answer: A. "I should contact the doctor if my temperature is 100.4�F (38�C) or higher."

Because of the client’s increased risk for infection, successful teaching is indicated when the client states that she will contact the doctor if her temperature is 100.4�F (38�C) or greater. The client should be instructed to monitor her temperature twice daily. The client should refrain from coitus, douching, and tub bathing, which can increase the potential for infection. Showering is permitted because water in the shower doesn’t enter the vagina and increase the risk of infection. A fluid intake of at least 2 L daily is recommended to prevent potential urinary tract infection.

Correct answer: C. Check the status of the fetal heart rate.

The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse’s first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to her right side is not necessary. If the cord does prolapse, the client should be placed in a knee-to-chest or Trendelenburg position. Checking the fluid with nitrazine paper and vaginal examination are appropriate once the status of the fetus has been evaluated.

Correct answer: A. There is evidence of fetal well-being.

The nonstress test is considered reactive when two or more fetal heart rate accelerations of at least 15 bpm occur (from a baseline fetal heart rate of 120 to 160 bpm), along with fetal movement, during a 10- to 20-minute period. A reactive nonstress test indicates fetal heart rate accelerations and well-being. There is no indication for further evaluation (such as a contraction stress test). However, contraction stress tests are commonly scheduled for pregnant clients with insulin-dependent diabetes in the latter part of pregnancy and are repeated periodically until birth. Chorionic villus sampling is usually performed early in the pregnancy to detect fetal abnormalities.

Correct answer: C. Inconsistent late decelerations.

A contraction stress test is used to evaluate fetal well-being during a simulated labor. A suspicious contraction stress test indicates inconsistent late deceleration patterns requiring further evaluation. A negative contraction stress test indicates no late decelerations and is the desired outcome. A positive contraction stress test indicates fetal compromise with frequent late decelerations. Fetal movements are one of the parameters of a biophysical profile and are detected with nonstress testing. Decreased or absent fetal movements may indicate central nervous system dysfunction or prematurity. Lack of fetal movement or decreased fetal movement is not associated with contraction stress testing.

Correct answer: A. It is noninvasive using real-time ultrasound.

The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity. Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn’s Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound requires the mother to have a full bladder.

Correct answer: D. They will decrease.

During the first trimester, it is not unusual for insulin needs to decrease, commonly as a result of nausea and vomiting. Progressive insulin resistance is characteristic of pregnancy, particularly in the second half of pregnancy. It is not unusual for insulin needs to increase by as much as four times the nonpregnant dose after about the 24th week of gestation. This resistance is caused by the production of human placental lactogen, also called human chorionic somatotropin, by the placenta and by other hormones, such as estrogen and progesterone, which are insulin antagonists.

Correct answer: D. Twin-to-twin transfer.

Clients who are pregnant and have diabetes are not at greater risk for multifetal pregnancy and subsequent twin-to-twin transfer unless they have undergone fertility treatments. The pregnant diabetic client is at higher risk for complications such as infection, polyhydramnios, ketoacidosis, and preeclampsia, compared with the pregnant nondiabetic client.

Correct answer: C. 70 to 100 mg/dL (3.3 to 5.6 mmol/L) before meals and bedtime snacks.

The goal is to maintain blood plasma glucose levels at 70 to 100 mg/dL (3.5 to 5.6 mmol/L) before meals and bedtime snacks. Below 60 mg/dL (5.6 mmol/L) indicates hypoglycemia. A range of 110 to 140 mg/dL (6.2 to 7.8 mmol/L) suggests hyperglycemia. The target range 1 hour after meals is 100 to 120 mg/dL (5.6 to 6.7 mmol/L).

Correct answer: D. Maternal infection.

Maternal infection is the most common cause of maternal hyperglycemia and can lead to ketoacidosis, coma, and death. The client should notify the primary health care provider immediately if she experiences symptoms of an infection. Fetal macrosomia, obesity before conception, and pregnancy-induced hypertension are not associated with maternal hyperglycemia during pregnancy.

Correct answer: C. Dehydration.

Dehydration, polyuria, fatigue, flushed hot skin, dry mouth, and drowsiness are manifestations of hyperglycemia. Hyperglycemia is a medical emergency and requires immediate action to prevent maternal and fetal mortality. Pallor, sweating, and nervousness are early signs of hypoglycemia, not hyperglycemia.

Correct answer: D. Stillbirth.

Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean section is necessary. Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia.

Correct answer: C. They fall significantly in the immediate postpartum period.

Insulin needs fall significantly for the first 24 hours postpartum because the client has usually been on nothing-by-mouth status for a period of time during labor and the labor process has used maternal glycogen stores. If the client breast-feeds, lower blood glucose levels decrease the insulin requirements. With insulin resistance gone, the client commonly needs little or no insulin during the immediate postpartum period. Although the need for insulin decreases during the intrapartum period, the insulin requirements fall further during the first 24 hours postpartum. After the first 24 hours postpartum, insulin requirements may fluctuate markedly, needing adjustment during the next few days as the mother’s body returns to a nonpregnant state.

Correct answer: D. "I should reduce my intake of protein in my diet."

The client needs a diet that is adequate in protein and calories to prevent anemia, which can place additional strain on the cardiac system, further compromising the client’s cardiac status. The client should avoid contact with people who have infections because of the increased risk for developing endocarditis. The client may need antibiotics during the pregnancy to prevent endocarditis. Limiting sodium intake can help to prevent excessive expansion of blood volume and decrease cardiac workload.

Correct answer: B. Increased dyspnea at rest.

Increased dyspnea at rest must be reported immediately because it may be indicative of increasing congestive heart failure. Mild ankle edema in the third trimester is a common finding. However, generalized or pitting edema, suggesting increasing congestive heart failure, must be reported immediately. Emotional stress on the job increases cardiac demand. However, it needs to be reported only if the client experiences symptoms, such as palpitations or irregular heart rate, indicating heart failure related to the increased stress. Weight gain of 1 lb (0.45 kg) per week is a normal finding during the third trimester.

Correct answer: A. Continuation of the same dosage.

Unless the client has cardiac decompensation during the pregnancy, she will most likely be able to continue taking the same dose of medication. The client may be prescribed prophylactic antibiotics, particularly if she has had rheumatic fever. The medication would be switched only if digitalis toxicity occurs. A diuretic is added only if congestive heart failure is not controlled by sodium and activity restrictions.

Correct answer: D. Heparin.

Although there is no completely safe anticoagulant therapy during pregnancy, heparin is typically the drug of choice. Warfarin, a pregnancy category D drug, can cause fetal malformations. Enoxaparin is sometimes used, but clients are typically switched to heparin near labor because enoxaparin used along with spinal or epidural anesthesia presents an increased risk of bleeding in the epidural or spinal space. Ardeparin also can cause fetal malformations.

Correct answer: C. Increase caloric intake to 2,200 cal daily to promote fetal growth.

The client can continue a low-sodium diet but should increase the caloric intake to 2,200 cal daily to provide adequate nutrients to support fetal growth and development. Folic acid supplements, a standard component of care, are used to prevent folic acid deficiency, which is associated with megaloblastic anemia during pregnancy. Severe restriction of sodium intake is not recommended because sodium is necessary to maintain fluid volume. Iron supplements should be taken with acidic foods and fluids (eg, citrus juices) for maximum absorption. Milk decreases the absorption of iron.

Correct answer: C. Ectopic pregnancy.

The client’s signs and symptoms indicate a probable ectopic pregnancy, which can be confirmed by ultrasound examination or by culdocentesis. The primary health care provider is notified immediately because hypovolemic shock may develop without external bleeding. Once the fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae would be manifested by a board-like uterus in the third trimester. Gestational trophoblastic disease would be suspected if the client exhibited no fetal heart rate and symptoms of pregnancy-induced hypertension before 20 weeks’ gestation. A client with a complete abortion would exhibit a normal pulse and blood pressure with scant vaginal bleeding.

Correct answer: B. All of the above

The client may be experiencing an ectopic pregnancy. Contributing factors to an ectopic pregnancy include a prior history of sexually transmitted infection that can scar the fallopian tubes. Multiple sex partners increase the risk of sexually transmitted infections. Knowledge of the client’s last menstrual period and contraceptive use may support or rule out the possibility of an ectopic pregnancy. The client’s history of cesarean sections would not contribute information valuable to the client’s current situation or potential diagnosis of ectopic pregnancy.

Correct answer: A. Falling hematocrit and hemoglobin levels.

Falling hematocrit and hemoglobin levels indicate shock, which occurs if the tube ruptures. Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain and referred shoulder pain. The amount of vaginal bleeding that is evident is a poor estimate of actual blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse. Abdominal edema is a late sign of a tubal rupture in ectopic pregnancy.

Correct answer: D. Pulse rate.

Fallopian tube rupture is an emergency situation because of extensive bleeding into the peritoneal cavity. Shock soon develops if precautionary measures are not taken. The nurse readying a client for surgery should be especially careful to monitor blood pressure and pulse rate for signs of impending shock. The nurse should be prepared to administer fluids, blood, or plasma expanders as necessary through an intravenous line that should already be in place. Because the fertilized ovum has implanted outside the uterus, uterine cramping is unlikely. However, abdominal tenderness or knife-like pain may occur. Abdominal fullness may be present, but abdominal distention is rare unless peritonitis has developed. Although the hemoglobin and hematocrit may be checked routinely before surgery, the laboratory results may not truly reflect the presence or degree of acute hemorrhage.

Correct answer: A. Episodes of pelvic inflammatory disease.

Anything that causes a narrowing or constriction in the fallopian tubes so that a fertilized ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy. Pelvic inflammatory disease is the most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic pregnancy is not related to urinary tract infections. Use of marijuana during pregnancy is not associated with ectopic pregnancy, but its use can result in cognitive reduction if the mother’s use during pregnancy is extensive. Progestin-only contraceptives and intrauterine devices have been associated with ectopic pregnancy.

Correct answer: D. "I’ll eat two large meals daily with frequent protein snacks."

The client needs further instructions when she says she should eat two meals a day with frequent protein snacks to decrease nausea and vomiting. The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting. Eating dry crackers or toast before arising, consuming fluids separately from meals, and avoiding greasy or spicy foods may also help to decrease nausea and vomiting.

Correct answer: B. Hypokalemia.

Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased metabolism of nutrients, and excessive vomiting.

Correct answer: A. Estrogen.

Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotropin production. Hyperemesis is also associated with infectious conditions, such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole. Progesterone is a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone.

Correct answer: B. Obtain an ultrasound.

The nurse should prepare the client for an ultrasound to determine the cause of the symptoms. Elevated blood pressure at this point in the pregnancy could indicate chronic hypertension as well as hydatidiform mole. The fundal height of 19 cm is higher than is typically found at 15 weeks’ gestation and is indicative of a molar pregnancy (hydatidiform mole). The dark brown vaginal bleeding in isolation could indicate an abortion but when placed in context of the other symptoms is likely related to a hydatidiform mole. The continuous nausea and vomiting is abnormal at this point in the pregnancy and can be a result of the high levels of progesterone from a molar pregnancy. There is no fetus involved; the blood pressure elevation and the continuous nausea and vomiting will resolve with evacuation of the mole, negating the need for magnesium sulfate therapy and placing the client on NPO status.

Correct answer: B. Pregnancy-induced hypertension.

Hydatidiform mole is suspected when the following are present: pregnancy-induced hypertension before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from cardiac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies.

Correct answer: B. Hemorrhage.

After D&C to evacuate a molar pregnancy, the nurse should assess the client’s vital signs and monitor for signs of hemorrhage, because the surgical procedure may have traumatized the uterine lining, leading to hemorrhage. Urinary tract infections, not common after evacuation of a molar pregnancy, are most commonly related to urinary catheterization. Typically, urinary catheters are not used during evacuation of a molar pregnancy. The client should not experience abdominal distention, because the contents of the uterus have been removed. Chorioamnionitis is an inflammation of the amniotic fluid membranes. With complete mole, no embryonic or fetal tissue or membranes are present.

Correct answer: A. Ectopic pregnancy.

A client who has had a hydatidiform mole removed should have regular checkups to rule out the presence of choriocarcinoma, which may complicate the client’s clinical picture. The client’s human chorionic gonadotropin (hCG) levels are monitored for 1 year. During this time, she should be advised not to become pregnant because this would be reflected in rising hCG levels. Ectopic or multifetal pregnancy is not associated with hydatidiform mole. Women who have molar pregnancies have fertility rates similar to the general population.

Correct answer: C. 12 months.

A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.

Correct answer: A. Client at 38 weeks’ gestation with active herpes lesions.

Herpes simplex virus can be transmitted to the infant during a vaginal birth. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions-primary or secondary-are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb (3,629 g) will be given a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months’ gestation, the breech position is not a concern.

Correct answer: C. "I have this disease because I don’t eat enough food with iron."

Sickle cell disease is an autosomal recessive disorder requiring both parents to have a sickle cell trait to pass the disease to a child. Deoxygenated hemoglobin cells assume a sickle shape and obstruct tissues. Tissue obstruction causes hypoxia to the area (vaso-occlusion) and results in pain, called sickle cell crisis. This type of anemia is an inherited disorder; it is not caused by lack of iron in the diet. Self-monitoring for any type of infections or sickle cell crisis and increased frequency of antenatal care visits are part of the teaching plan of care.

Correct answer: C. All of the above

Having the fetus at a negative station places the client at risk for a cord prolapse. With a negative station, there is room between the fetal head and the maternal pelvis for the cord to slip through. A small infant is more mobile within the uterus and the cord can rest between the fetus and the inside of the uterus or below the fetal head. With a large infant, the head is usually in a vertex presentation and occludes the lower portion of the uterus, preventing the cord from slipping by. When membranes rupture, the cord can be swept through with the amniotic fluid. In a breech presentation, the fetal head is in the fundus and smaller portions of the fetus settle into the lower portion of the uterus, allowing the cord to lie beside the fetus. Prior abortion and a low lying placenta have no correlation to cord prolapse.

Correct answer: B. Rupture of membranes and Breech presentation.

A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum.

Correct answer: C. Take frequent naps.

This client is likely experiencing fatigue and should increase her periods of rest. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy. Asking the client to limit her activities may cause the client to become withdrawn. The information given does not support limiting activity. Increasing fluid intake will not reduce the fatigue. The information does not indicate that the client is immunosuppressed and should avoid contact with others.

Correct answer: A. O negative.

A routine serology study to confirm compatibility between a blood donor and recipient takes about 1 hour. In an emergency, O negative RBCs can be safely administered to most clients, which is why a person with O-negative blood is called a universal donor. The other types of RBCs may cause an adverse reaction.

Correct answer: C. Postpartum depression.

The client is experiencing and verbalizing signs of postpartum depression, which usually appears at about 4 weeks postpartum but can occur at any time within the first year after birth. It is more severe and lasts longer than postpartum blues, also called "baby blues." Baby blues are the mildest form of depression and are seen in the later part of the first week after birth. Symptoms usually disappear shortly. Depression may last several years and is disabling to the woman. Poor bonding may be seen at any time but commonly becomes evident as the mother begins interacting with the infant shortly after birth. Infant abuse may take the form of neglect or injuries to the infant. A depressed mother is at risk for injuring or abusing her infant.

Correct answer: C. Both of the above

The nursing assistant could assist the client with breathing and relaxation, and ambulate the postcesarean client to the bathroom. Removing a Foley catheter would also involve assessment of bladder status and totaling the intake and output and would be a nursing responsibility. Calculating the hourly IV totals for a preterm labor client would involve assessments that require nursing expertise. In-and-out catheterization, a sterile procedure, and calling reports to health care providers, which requires gathering and analysis of data, are responsibilities of the nurse.

Correct answer: A. A client at 32 weeks’ gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.

A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at 13 weeks’ gestation with nausea and vomiting is a concern because the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the insulin-dependent diabetic. The insulin-dependent diabetic is a high priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need additional testing to further evaluate fetal well-being.) The client who is at 17 weeks’ gestation may be too early in her pregnancy to experience fetal movement and would be the last person to be seen.

Correct answer: D. A woman at 32 weeks’ gestation and is preeclamptic with +3 proteinuria.

The nurse should refer the preeclamptic client with 3+ proteinuria to a health care provider. The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks’ gestation with insulin-dependent diabetes who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tablets until the client can obtain an appointment with the care provider. The client at 10 weeks’ gestation with nausea and vomiting and +1 ketones should also be seen by a health care provider, but at this point this client is uncomfortable but her life is not in danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancy and this would not be considered a problem that requires immediate referral to a health care provider

Correct answer: B. All of the above

The first action taken should be to evaluate the placenta previa patient who has pelvic pressure. The pelvic pressure may be caused by a fetal head creating pressure in the pelvis indicating a potential birth. This patient should be evaluated without a pelvic exam and then consult with the physician. A vaginal exam is contraindicated as it may stimulate bleeding of the placenta. The second action would be to complete an assessment on the client with pre-eclampsia and her fetus to evaluate for tolerance and effectiveness of the magnesium sulfate. The hyperemesis patient needs to be evaluated for hydration status and for medication. The preterm labor client is stable on the oral medication and should be seen last.

Correct answer: C. Anesthesia/pain level assessment every 30 minutes.

The nurse should monitor anesthesia/pain levels every 30 minutes during active labor to ascertain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client. When in active labor, oxygen saturation is not monitored unless there is a specific need, such as heart disease. The client should not be on her back but wedged to the right or left side to take the pressure off the vena cava. When lying on the back, the fetus compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30 minutes to 1 hour.

Correct answer: A. Every 30 minutes during the active phase.

Labor is categorized into three phases: latent, active, and transition. During the active stage of labor, intermittent fetal monitoring is performed every 30 minutes to detect changes in fetal heart rate such as bradycardia, tachycardia, or decelerations. If complications develop, more frequent or continuous electronic fetal monitoring may be needed. During the latent phase, intermittent monitoring is usually performed every 2 hours because contractions during this time are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 to 15 minutes because the client is getting closer to birth of the baby. There is no initial phase of labor.

Correct answer: B. Encourage the client to breathe through the urge to push.

The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. This may occur quickly with a multigravid client. Comfort measures are important for the client at this time, but are not the highest priority for the nurse.

Correct answer: B. Loss of control.

Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.

Correct answer: B. Soft tissue dystocia.

The obese pregnant client is more susceptible to soft tissue dystocia, which can impede the progress of labor. Symptoms of soft tissue dystocia would include an arrest of labor, prolonged labor, or an arrest of descent of the fetus. Hypotonic reflexes are associated with magnesium sulfate therapy, and increased uterine resting tone is associated with hypertonic labor patterns in early labor, not with obesity and pregnancy. Increased fear and anxiety are also not associated with obesity. However, they may be associated with a primigravid client who does not know what to expect during labor.

Correct answer: B. Notifying the health care provider of her current status.

The normal length of time for pushing is 2 hours. Anything over that time becomes an abnormal situation and the health care provider needs to be notified. Changing the client’s position is an appropriate nursing action within the 2-hour time period based on client need and fetal descent. Continuing current pushing supports techniques that have not been successful within the 2-hour time frame. Assessing client pain and fetal status are standards of care for laboring clients, but will not expedite childbirth for a client who has been pushing this long.

Correct answer: A. Softening of the cervix and beginning of effacement.

Prostaglandin gel may be used for cervical ripening before the induction of labor with oxytocin. It is usually administered by catheter or suppository, or by vaginal insertion. Two to three doses are usually needed to begin the softening process. Common adverse effects include nausea, vomiting, fever, and diarrhea. Continuous fetal heart rate monitoring and close monitoring of maternal vital signs are necessary to detect subtle changes or adverse effects. Prostaglandin gel usually does not initiate contractions; therefore, the rest period between contractions will be >2 minutes. There is no need to assess reflexes based on prostaglandin use. Leaking of amniotic fluid is not caused by the use of this gel.

Correct answer: D. Multiple gestation.

External cephalic version is the turning of the fetus from a breech position to the vertex position to prevent the need for a cesarean birth. Gentle pressure is used to rotate the fetus in a forward direction to a cephalic lie. Contraindications to the procedure include multiple gestation because of the potential for fetal injury or uterine injury, severe oligohydramnios (decreased amniotic fluid), contraindications to a vaginal birth (eg, cephalopelvic disproportion), and unexplained third trimester bleeding. If the mother has Rh-negative blood type, the procedure can be performed and Rh immunoglobulin should be administered in case minimal bleeding occurs. A history of gestational diabetes is not a contraindication unless the fetus is large for gestational age and the client has cephalopelvic disproportion.

Correct answer: B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.

The goal of oxytocin administration in labor augmentation is to establish an adequate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a palpable resting tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 cm/h is too rapid for the induction/augmentation process.

Correct answer: B. Squatting.

Anatomically, the best position for the client to assume is the squatting position because this enhances pelvic diameters and allows gravity to assist in the expulsion stage of labor. This position also provides for natural pressure anesthesia as the fetal presenting part presses on the stretched perineum. If the client is extremely fatigued from a lengthy labor process, she may prefer the dorsal recumbent position. However, this position is not considered the best position anatomically. The lithotomy position may be ineffective and uncomfortable for a client who is ready to push. The hands and knees position may help to alleviate some back pain. However, this position can cause discomfort to the arms and wrists and is tiring over a long period of time.

Correct answer: D. Uterus changes to discoid shape.

During transition, contractions are increasing in frequency, duration, and intensity. The most appropriate nursing problem is pain related to strength and duration of the contractions. Insufficient information is provided in the scenario to support the other listed nursing diagnoses. Urinary retention would be appropriate if the client had a full bladder and was unable to void. Hyperventilation might apply if client was breathing too rapidly, but there is no evidence this is occurring. Ineffective coping might apply if the client said, "I can’t do this" or something similar.

Correct answer: D. The cord lengthens outside the vagina.

The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes more firm and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage.

Correct answer: A. Walking around in the hallway.

Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single-room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus.

Correct answer: C. Light stroking of the skin surface.

Light stroking of the skin, or effleurage, is commonly used with the Lamaze method of childbirth preparation. Light abdominal massage with just enough pressure to avoid tickling is thought to displace the pain sensation during a contraction. Deep kneading and secure grasping are typically associated with relaxation massages to relieve stress. Prolonged pressure on specific sites is associated with acupressure.

Correct answer: A. Ruptured membranes.

Some primary health care providers do not allow clients with ruptured membranes to use a hot tub or jet hydrotherapy tub during labor for fear of infections. The temperature of the water should be between 98�F and 100�F (36.7�C to 37.8�C) to prevent hyperthermia. Jet hydrotherapy is not contraindicated for clients with multifetal gestation, diabetes mellitus, or hypotonic labor patterns.

Correct answer: A. Autosomal recessive and that unless the baby’s father has the gene, the baby will not have the disease.

Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan’s syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.

Correct answer: C. Lecithin-sphingomyelin (L/S ratio).

To determine fetal lung maturity, the sample of amniotic fluid will be tested for the L/S ratio. When fetal lungs are mature, the ratio should be 2:1. Bilirubin indicates hemolysis and, if present in the fluid, suggests Rh disease. Red blood cells should not appear in the amniotic fluid because their presence suggests fetal bleeding. Barr body determination is a chromosome analysis of the sex chromosomes that is sometimes used when a child is born with ambiguous genitalia.

Correct answer: B. Cephalopelvic disproportion (CPD).

Adolescent pregnancy carries an increased risk of pregnancy-induced hypertension, iron-deficiency anemia, and CPD. CPD is a concern because maturation of the skeletal bones (including the pelvis) is commonly not complete in adolescents. Adolescent labor does not differ from labor in the older woman if no CPD is present. A prolonged first stage of labor and poor fetal descent may indicate that CPD exists. Uterine inversion, a rapid third stage of labor, or decreased ability to push may occur regardless of the client’s age.

Correct answer: A. Offering encouragement and support.

The client is in the transition phase of the first stage of labor. During this phase, the client needs encouragement and support because this is a difficult and painful time, when contractions are especially strong. Usually, the client finds it difficult to maintain self-control. Everything else seems secondary to her as she progresses into the second stage of labor. Although ice chips may be given, typically the client does not desire sips of water. Labor is hard work. Generally, the client is perspiring and does not desire additional warmth. Frequent perineal cleansing is not necessary unless there is excessive amniotic fluid leaking.

Correct answer: D. Sagittal.

The sagittal suture is the most readily felt during a vaginal examination. When the fetus is in the LOA position, the occiput faces the mother’s left. The lambdoid suture is on the side of the skull. The coronal suture is a horizontal suture across the front portion of the fetal skull that forms the anterior fontanel. It may be felt with a brow presentation. The frontal suture may be felt with a brow or face presentation.

Correct answer: B. It usually lasts a day or two before resolving.

Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.

Correct answer: B. All of the above

Uterine inversion is indicated by a sudden gush of blood from the vagina leading to decreased blood pressure, and an inability to palpate the uterus since it may be in or protruding from the vagina and any signs of blood loss such as diaphoresis, paleness, or dizziness could be observed at this time. Intense pain and a hard contracting uterus are not associated with uterine inversion.

Correct answer: C. "I think my mother should give him the first feeding."

Avoidance, hostility, or low-key (passive) behavior toward the baby may be a cue to potential bonding problems. The nurse should encourage the client to give the baby the first feeding to begin the bonding process. Expressions of disappointment with the baby’s gender may also signal problems with maternal-infant bonding. Comparing the baby’s features to her own indicates identification of the neonate as belonging to her, suggesting bonding with neonate. Comparing the actual neonate with the "fantasized neonate" is a normal maternal reaction. Wanting to buy a blue outfit indicates an interest in and connection with the neonate and is a sign of bonding.

Correct answer: C. No pain.

According to the gate-control theory of pain, a closed gate means that the client should feel no pain. The gate-control theory of pain refers to the gate-control mechanisms in the substantia gelatinosa that are capable of halting an impulse at the level of the spinal cord so the impulse is never perceived at the brain level as pain (ie, a process similar to keeping a gate closed).

Correct answer: B. Bladder status.

The bladder status should be monitored throughout the labor process, but especially before the client begins pushing. A full bladder can impede the progress of labor and slow fetal descent. Because she has had an epidural anesthetic, it is most likely that the client is receiving intravenous fluids, contributing to a full bladder. The client also does not feel the urge to void because of the anesthetic. Although it is important to monitor membrane status and fetal heart rate variability throughout labor, this does not affect the client’s ability to push. There is no need to recheck cervical dilation because increasing the frequency of examinations can increase the client’s risk for infection.

Correct answer: C. Exhaustion.

The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client is having prolonged labor, the nurse should monitor the client for signs of exhaustion as well as dehydration. Hypotonic contractions, which are painful but ineffective, may be occurring. Oxytocin augmentation may be necessary. Chills and fever are manifestations of an infection and are not associated with a prolonged latent phase of labor. Fluid overload can occur from rapid infusion of intravenous fluids administered if the client is experiencing hemorrhage or shock. It is not associated with prolonged latent phase. The client’s membranes are intact, so it would be difficult to assess meconium staining of the fluid. Meconium-stained fluid is associated with fetal distress, and this fetus appears to be in a healthy state, as evidenced by a fetal heart rate within normal range and good variability.

Correct answer: C. Provide firm pressure to the client’s sacral area.

The client who has back pain during labor experiences marked discomfort because the fetus is in an LOP position. This pain is much greater than when the fetus is in the anterior position because the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application of firm pressure to the sacral area can help alleviate the pain. Problems of severe back pain during labor do not typically require a cesarean birth. The primary health care provider may elect to do an episiotomy, but it is not necessarily required. It is unlikely that a primigravid client with a fetus in an LOP position will have a precipitous birth; rather, labor is usually more prolonged. A hands-and-knees position or a right side-lying position may help to rotate the fetal head and thus alleviate some of the back pain.

Correct answer: B. Rapid, shallow chest breathing.

The psychoprophylaxis method of childbirth suggests using slow chest breathing until it becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70 breaths/min. Deep chest breathing is appropriate for the early phase of labor, in which the client exhibits less frequent contractions. When transition nears, a rapid pant-blow pattern of breathing is used. Slow abdominal breathing is very difficult for clients in labor.

Correct answer: B. Increase in the fetal heart rate and variability.

Fetal scalp stimulation is commonly prescribed when there is decreased fetal heart rate variability. Pressure is applied with the fingers to the fetal scalp through the dilated cervix. This should cause a tactile response in the fetus and increase the fetal heart rate and variability. However, if the fetus is in distress and becoming acidotic, fetal heart rate acceleration will not occur. The fetal hematocrit level can be measured by fetal blood sampling. Scalp stimulation does not increase the strength of the contractions. However, it can increase fetal heart rate and variability. Fetal position is assessed by identifying skull landmarks (sutures) during a vaginal examination.

Correct answer: C. 7.2.

If the fetus is hypoxic, the pH will fall below 7.2 and be indicative of fetal distress. This finding typically requires immediate vaginal or cesarean birth. A scalp pH reading of 7.21 to 7.25 should be repeated again in 30 minutes for assessment of hypoxia and acidosis.

Correct answer: D. Posterior.

When a client has severe back pain during labor, the fetus is most likely in an occipitoposterior position. This means that the fetal head presses against the client’s sacrum, causing marked discomfort during contractions. These sensations may be so intense that the client requests medication for relief of the back pain rather than the contractions. Breech presentation and transverse lie are usually known prior to 8-cm dilation and a cesarean section is performed. Fetal occiput anterior position does not increase the pain felt during labor.

Correct answer: B. All of the above

Decelerations alert the nurse that the fetus is experiencing decreased blood flow from the placenta. Administering oxygen will increase tissue perfusion. Placing the mother on her side will increase placental perfusion and decrease cord compression. Using an internal fetal monitor would help in identifying the possible underlying cause of the decelerations, such as metabolic acidosis. Assessing for pain relief and readjusting the monitor would have no effect on correcting the late decelerations.

Correct answer: B. To determine whether the fetal presenting part is engaged.

Leopold’s maneuvers are performed to determine the presentation and position of the fetus. The third maneuver determines whether the fetal presenting part is engaged in the maternal pelvis. The first maneuver distinguishes between a breech and a cephalic presentation through palpation of the top of the fundus. The second maneuver locates the fetal back, arms, and legs. The fetal heart rate monitoring device should be placed near the fetal skull and back for optimal fetal heart rate monitoring. The fourth maneuver is done to locate the fetal cephalic prominence if the fetus is in a cephalic position.

Correct answer: A. Immediately notify the primary health care provider of the client’s symptoms.

Small clots that are expressed during fundal examination in the immediate postpartum period are normal; however, large clots are indicative of retained placental tissue. A small trickle of bright red vaginal bleeding may indicate a laceration. The nurse should notify the primary health care provider immediately of these findings, because uterine atony may occur and the laceration, if present, needs to be repaired to prevent further blood loss. Continuing to monitor the client every 15 minutes is the standard of care for a postpartum client. Taking no action would indicate that the nurse thinks passage of clots and trickling of bright red blood is a normal situation, which it is not. Methylergonovine is a powerful drug that contracts the uterus, but it usually is not administered to a client with a blood pressure of 136/92 mm Hg because of its hypertensive effects. Changing the perineal pads every 15 minutes is not helpful if the client is experiencing a hemorrhage.

Correct answer: D. It is too early in labor for the epidural but your obstetrician has prescribed IV medication to keep you comfortable until you have dilated 1 to 2 cm more.

Epidurals are given when labor is established, usually at 3- to 4-cm dilation. The effect of the epidural should be that labor will continue and not be slowed down by the administration of the epidural. The use of an epidural is not correlated with rupture of membranes. The contraction pattern for this client is adequate, not slow, and considered normal for 2 cm dilation. Epidurals are given at 3- to 4-cm dilation, and if there is medication available, it can be given to make the client comfortable until an epidural can be given.

Correct answer: C. All of the above

A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from 10-cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a multiparous client than it will for a primiparous client, as the entire labor process takes less time for someone who has had a baby before. This client will withdraw into herself during transition and this is a common characteristic for those in the transition phase.

Correct answer: B. Reposition the client and continue to evaluate the tracing.

The cause of variable decelerations is cord compression, which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, oxygen should be initiated but the rate should be 8 to 10 L/min. Notifying the primary health care provider should occur if turning the client and administering oxygen do not relieve the decelerations.

Correct answer: B. All of the above

Knowledge of how the fetus is tolerating contractions as well as the frequency, intensity, and duration of contractions, as indicated on the fetal monitor strip, are extremely important. The type of analgesia or anesthesia being used, the client’s response, and her pain rating should be included as well. The amount of vaginal bleeding indicates whether this labor is in the normal range. Vaginal discharge indicates if membranes are ruptured and the color, odor, and amount of amniotic fluid. The support persons with the client are an integral part of the labor process and greatly influence how she manages labor emotionally and, commonly, physically. A complete change-of-shift report would include the client’s name, age, gravida and parity, current and prior illnesses that may influence this hospitalization, prior labor and birth history if applicable, last vaginal examination time and findings, vaginal bleeding, support persons with client, current IVs and other medications being used, and pertinent laboratory test results. Future plan for birth control would be the least important information to be given to the next shift because it will not impact the labor care plan.

Correct answer: C. Complete a vaginal examination to determine dilation, effacement, and station.

The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client’s signs and symptoms by checking to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone hydrochloride (Narcan) available are important. Narcan completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining Narcan. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.

Correct answer: A. Naloxone hydrochloride (Narcan).

Naloxone hydrochloride (Narcan) would not be used in a client who has a history of drug addiction. Narcan would abruptly withdraw this woman from the drug she is addicted to as well as the nalbuphine. The withdrawal would occur within a few minutes of injection and, if severe enough, could jeopardize the mother and fetus. Xylocaine is a local anesthetic and numbs rather than decreases the effects of Narcan. The local anesthetic and the pudendal block are both appropriate for this birth but are used to numb the maternal perineum for birth.

Correct answer: C. Hypotension.

When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia.

Correct answer: A. To contract the mother’s uterus.

After an emergency birth, the nurse suggests that the mother begin breast-feeding to contract the uterus. Breast-feeding stimulates the natural production of oxytocin. In a multiparous client, uterine atony is a potential complication because of the stretching of the uterine fibers following each subsequent pregnancy. Although breast-feeding does help to begin the parental-infant bonding process, this is not the primary reason for the nurse to suggest breast-feeding. Prevention of neonatal hypothermia is accomplished by placing blankets on both the neonate and the mother. Although colostrum in breast milk provides the neonate with nutrients and immunoglobulins, the primary reason for breast-feeding is to stimulate the natural production of oxytocin to contract the uterus.

Correct answer: A. Provide the client with a warm blanket.

A chill shortly after birth is a common, normal occurrence. Warm blankets can help provide comfort for the client. It has been suggested that the shivering response is caused by a difference between internal and external body temperatures. A different theory proposes that the woman is reacting to fetal cells that have entered the maternal bloodstream through the placental site. Assessing the client’s pulse rate will provide no further information about the chill. Decreasing the IV rate will not influence the length of time the client trembles. Assessing blood loss is a standard of care at this point postpartum but has no correlation to the chill.

Correct answer: A. Assess the fetal heart rate (FHR) for 1 full minute.

After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the primary health care provider. A cord prolapse requires prompt birth by cesarean section. The client’s contraction pattern should be monitored once labor has been established. The client’s temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern is present.

Correct answer: D. Turning on the infant warmer.

Nursing care for this client includes providing support, preparing for childbirth, assessing for potential complications, and providing for care of the newborn. Turning on the warmer is the best choice for providing for the care of the newborn. Oxygen and IV fluids may be indicated if variable or late decelerations are noted on the fetal heart monitor, but decelerations are not indicated in the question. It is likely too late for pharmacologic pain relief for a multigravid client. Education regarding care of the newborn is not appropriate at this time.

Correct answer: C. Caput succedaneum.

Caput succedaneum is common after the use of a vacuum extractor to assist the client’s expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is not a common finding.

Correct answer: D. All of the above

The range of fetal heart rate fluctuating too high and low could indicate fetal distress. The green peripad fluid indicates meconium, which could be associated with fetal distress. Increased fetal activity during labor may also indicate distress. The maternal vital signs noted and a perineal pad with blood and mucus are normal findings.

Correct answer: D. Assess the fetal heart rate pattern.

After spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical cord out of the birth canal. Sudden deceleration of the fetal heart rate commonly signifies cord compression and/or prolapse of the cord, which would require immediate birth. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the client to the right side is not a priority action. However, changing the client’s position would be appropriate if variable decelerations are present. The nurse should assess the color, amount, and odor of the fluid, but this can be done once the fetal heart rate is assessed and no problems are detected. Cervical dilation should be checked but only after the fetal heart rate pattern is assessed

Correct answer: D. Both of the above

The pressure from the fetus descending into the birth canal can cause the client to feel she needs to move her bowels and could be near childbirth. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in a birth in the bathroom. Applying a fetal monitor may reassure the nurse that the fetus is doing well; however, it does not help to determine if the fetus is ready to be born, which is the higher priority in this situation. Regardless of the client’s prior experience with back labor pain, the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the feeling of pressure with a bowel movement.

Correct answer: C. Acid level of the stomach contents.

Cimetidine (Tagamet) is prescribed by some anesthesiologists who will be giving a general anesthetic to reduce the level of acid in the stomach contents, altering the pH to reduce the risk of complications should aspiration of vomitus occur. Aspiration of vomitus is the fifth most common cause of maternal mortality. Most anesthesiologists insert an endotracheal tube to reduce the incidence of aspiration. Isoproterenol (Isuprel) is used to decrease the incidence of bronchospasm. Atropine sulfate is administered to dry oral and nasal secretions. Although cimetidine is useful for gastric ulcer therapy, gastric ulcers are not a common effect associated with operative births.

Correct answer: B. Side-lying.

Lumbar epidural anesthesia is usually administered with the client in a sitting or a left side-lying position with shoulders parallel and legs slightly flexed. These positions expose the vertebrae to the anesthesiologist. Paracervical and local anesthetics are usually administered with the client in the lithotomy position. The knee-to-chest and prone positions are not used for anesthesia administration.

Correct answer: A. Contractions will decrease in frequency, intensity, and duration.

The expected outcome of magnesium sulfate administration is suppression of the contractions because the client is in preterm labor. Magnesium sulfate is a smooth muscle relaxant used to slow and stop contractions. Having contractions that lead to birth is not the intended effect of this drug when used for preterm labor. Respirations lower than 12 breaths/min may indicate magnesium sulfate toxicity. Another use of magnesium sulfate is to treat preeclampsia by preventing seizures and, secondarily, lowering maternal blood pressure. However, in this scenario, preterm labor-not preeclampsia-is being treated.

Correct answer: C. The neonate will be born with mature lungs.

Betamethasone is a corticosteroid that induces the production of surfactant. The pulmonary maturation that results causes the fetal lungs to mature more rapidly than normal. Because the lungs are mature, the risk of respiratory distress in the neonate is lowered but not eliminated. Betamethasone also decreases the surface tension within the alveoli. Betamethasone has no influence on contractions or carrying the fetus to full term. It also does not prevent infection.

Correct answer: C. Oxytocin 30 units in 500 mL D5W.

A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a -1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents and the doses are accurate; however, cervical ripening has already taken place.

Correct answer: B. Dinoprostone.

Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must occur before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include dinoprostone, misoprostol, and prostaglandin E2. Nalbuphine is a narcotic analgesic used in early labor and has no influence on the cervix. Betamethasone is a corticosteroid given to mature fetal lungs.

Correct answer: D. "I can have an epidural as soon as I start contracting."

Typically, a client will be able to have an epidural when she is 3 to 4 cm dilated or the active phase of labor has been established. Waiting until the cervix is dilated to this point ensures that the client is in labor and the epidural is less likely to halt labor contractions. Nalbuphine and promethazine are used to provide relief until the client is about 7 cm dilated. If given after this time, narcotics may cause neonatal respiratory depression in the neonate. The majority of clients have an epidural or spinal for a cesarean section. The only time general anesthesia is used is for an emergency cesarean section.