HESI Maternity Exam 2

A primigravida asks the nurse about signs she can look for that would

indicate that the onset of labor is getting closer. The nurse should describe:

A) weight gain of 1 to 3 lbs.

B) quickening.

C) fatigue and lethargy.

D) bloody show.

The nurse should tell a primigravida that the definitive sign indicating that

labor has begun would be:

A) progressive uterine contractions with cervical change.

B) lightening.

C) rupture of membranes.

D) passage of the mucous plug (operculum).

On completion of a vaginal examination on a laboring woman, the nurse

records: 50%, 6 cm, -1. What is a correct interpretation of the data?

A) The fetal presenting part is 1 cm above the ischial spines.

B) Effacement is 4 cm from completion.

C) Dilation is 50% completed.

D) The fetus has achieved passage through the ischial spines.

In order to accurately assess the health of the mother accurately during

labor, the nurse should be aware that:

A) The woman's blood pressure increases during contractions and falls back

to prelabor normal between contractions.

B) Use of the Valsalva maneuver is encouraged during the second stage of

labor to relieve fetal hypoxia.

C) Having the woman point her toes reduces leg cramps.

D) The endogenous endorphins released during labor raise the woman's pain

threshold and produce sedation.

The nurse knows that the second stage of labor, the descent phase, has

begun when:

A) the amniotic membranes rupture.

B) The cervix cannot be felt during a vaginal examination.

C) The woman experiences a strong urge to bear down.

D) The presenting part is below the ischial spines.

Nurses can help their clients by keeping them informed about the distinctive

stages of labor. What description of the phases of the first stage of labor is

accurate?

A) Latent: mild, regular contractions; no dilation; bloody show; duration of 2

to 4 hours

B) Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to

6 hours

C) Lull: no contractions; dilation stable; duration of 20 to 60 minutes

D) Transition: very strong but irregular contractions; 8 to 10 cm dilation;

duration of 1 to 2 hours

Which position would the nurse suggest for second-stage labor if the pelvic

outlet needs to be increased?

A) Semirecumbent

B) Sitting C)

Squatting

D) Side-lying

Concerning the third stage of labor, nurses should be aware that:

A) the placenta eventually detaches itself from a flaccid uterus

B) The duration of the third stage may be as short as 3 to 5 minutes

C) it is important that the dark, roughened maternal surface of the placenta

appear before the shiny fetal surface

D) the major risk for women during the third stage is a rapid heart rate

The charge nurse on the maternity unit is orienting a new nurse to the unit

and explains that the 5 Ps of labor and birth are: (Select all that apply.)

A) passenger.

B) placenta.

C) passageway.

D) psychologic response.

E) powers.

F) position.

Nurses can advise their patients that which of these signs precede labor?

(Select all that apply.)

A. A return of urinary frequency as a result of increased bladder pressure

B. Persistent low backache from relaxed pelvic joints

C. Stronger and more frequent uterine (Braxton Hicks) contractions

D. A decline in energy, as the body stores up for labor

E. Uterus sinks downward and forward in first-time pregnancies.

The maternity nurse should notify the health care provider about which

assessment findings during labor? (Select all that apply.)

A. Positive urine drug screen

B. Blood glucose level of 78 mg/dL

C. Increased systolic blood pressure during first stage

D. Elevated white blood cell count

E. Oral temperature of 99.8° F

F. Respiratory rate of 10 breaths/min

A laboring woman becomes anxious during the transition phase of the first

stage of labor and develops a rapid and deep respiratory pattern. She

complains of feeling dizzy and light-headed. The nurse's immediate response

would be to:

A. encourage the woman to breathe more slowly.

B. help the woman breathe into a paper bag.

C. turn the woman on her side.

D. administer a sedative.

A woman is in the second stage of labor and has a spinal block in place for

pain management. The nurse obtains the woman's blood pressure and notes

that it is 20% lower than the baseline level. Which action should the nurse

take?

A. Encourage her to empty her bladder.

B. Decrease her intravenous (IV) rate to a keep vein-open rate.

C. Turn the woman to the left lateral position or place a pillow under her hip.

D. No action is necessary since a decrease in the woman's blood pressure is

expected.

A woman in latent labor who is positive for opiates on the urine drug screen

is complaining of severe pain. Maternal vital signs are stable, and the fetal

heart monitor displays a reassuring pattern. The nurse's MOST appropriate

analgesic for pain control is:

A. fentanyl (Sublimaze).

B.promethazine (Phenergan).

C. butorphanol tartrate (Stadol).

D. nalbuphine (Nubain).

A woman is experiencing back labor and complains of constant, intense pain

in her lower back. An effective relief measure is to use:

A. counterpressure against the sacrum.

B. pant-blow (breaths and puffs) breathing techniques.

C. effleurage.

D. biofeedback.

Nurses should be aware of the difference experience can make in labor pain,

such as:

A. sensory pain for nulliparous women often is greater than for multiparous

women during early labor.

B. affective pain for nulliparous women usually is less than for multiparous

women throughout the first stage of labor.

C. women with a history of substance abuse experience more pain during

labor.

D. multiparous women have more fatigue from labor and therefore

experience more pain.

With regard to what might be called the tactile approaches to comfort

management, nurses should be aware that:

A. either hot or cold applications may provide relief, but they should never be

used together in the same treatment.

B. acupuncture can be performed by a skilled nurse with just a little training.

C. hand and foot massage may be especially relaxing in advanced labor

when a woman's tolerance for touch is limited.

D. therapeutic touch (TT) uses handheld electronic stimulators that produce

sympathetic vibrations.

With regard to systemic analgesics administered during labor, nurses should

be aware that:

A. systemic analgesics cross the maternal blood-brain barrier as easily as

they do the fetal blood-brain barrier.

B. effects on the fetus and newborn can include decreased alertness and

delayed sucking.

C. IM administration is preferred over IV administration.

D. IV patient-controlled analgesia (PCA) results in increased use of an

analgesic.

After change of shift report, the nurse assumes care of a multiparous patient

in labor. The woman is complaining of pain that radiates to her abdominal

wall, lower back, buttocks, and down her thighs. Before implementing a plan

of care, the nurse should understand that this type of pain is:

A. visceral.

B. referred.

C. somatic.

D. afterpain.

When monitoring a woman in labor who has just received spinal analgesia,

the nurse should report which assessment findings to the health care

provider? (Select all that apply.)

A. Maternal blood pressure of 108/79

B. Maternal heart rate of 98

C. Respiratory rate of 14 breaths/min

D. Fetal heart rate of 100 beats/min

E. Minimal variability on a fetal heart monitor

After delivering a healthy baby boy with epidural anesthesia, a woman on the

postpartum unit complains of a severe headache. The nurse should

anticipate which actions in the patient's plan of care? (Select all that apply.)

A. Keeping the head of bed elevated at all times

B. Administration of oral analgesics

C. Avoid caffeine

D. Assisting with a blood patch procedure

E. Frequent monitoring of vital signs

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease

in the baseline rate from 155 to 110. The rate of 110 persists for more than

10 minutes. The nurse could attribute this decrease in baseline to:

A. maternal hyperthyroidism.

B. initiation of epidural anesthesia that resulted in maternal hypotension.

C. maternal infection accompanied by fever.

D. alteration in maternal position from semirecumbent to lateral.

On review of a fetal monitor tracing, the nurse notes that for several

contractions, the fetal heart rate decelerates as a contraction begins and

returns to baseline just before it ends. The nurse should:

A. describe the finding in the nurse's notes.

B. reposition the woman onto her side.

C. call the physician for instructions.

D. administer oxygen at 8 to 10 L/min with a tight face mask.

A. describe the finding in the nurse's notes

Which finding meets the criteria of a reassuring fetal heart rate (FHR)

pattern?

A. FHR does not change as a result of fetal activity.

B. Average baseline rate ranges between 100 and 140 beats/min.

C. Mild late deceleration patterns occur with some contractions.

D. Variability averages between 6 to 10 beats/min.

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 1½

to 2 minutes. The nurse's IMMEDIATE action would be to:

A. change the woman's position.

B. stop the Pitocin.

C. elevate the woman's legs.

D. administer oxygen via a tight mask at 8 to 10 L/min.

You are evaluating the fetal monitor tracing of your client, who is in active

labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of

125 down to 80. You reposition the mother, provide oxygen, increase IV fluid,

and perform a vaginal examination. The cervix has not changed. Five

minutes have passed, and the FHR remains in the 80s. What additional

nursing measures should you take?

A. Notify nursery nurse of imminent delivery.

B. Insert a Foley catheter.

C. Start oxytocin (Pitocin).

D. Notify the primary health care provider immediately (HCP).

When using intermittent auscultation (IA) to assess uterine activity, nurses

should be aware that:

A. the examiner's hand should be placed over the fundus before, during, and

after contractions.

B. the frequency and duration of contractions are measured in seconds for

consistency.

C. contraction intensity is given a judgment number of 1 to 7 by the nurse

and client together.

D. the resting tone between contractions is described as either placid or

turbulent.