1. A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
A) Ischial spines are the narrowest diameter of the pelvis B) Ischial spines are the widest diameter of the pelvis C) They represent the inlet of birth canal D) They measure pelvic floor
2. The nurse instructs a client on the difference between true labor and false labor. The nurse explains, 'In true labor:
A) Uterine contractions will weaken with walking.' B) Uterine contractions will strengthen with walking.' C) The cervix does not dilate.' D) The fetus does not descend.'
3. A first-trimester primigravida is diagnosed with anemia.The nurse should suspect that this anemia is a result of:
A) Mother - s increased blood volume B) Mother - s decreased blood volume C) Fetal blood volume increase D) Increase in iron absorption
4. In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A) First trimester B) Second trimester C) Third trimester D) Every trimester
5. A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
A) Reverse Trendelenburg B) Fowler - s C) Trendelenburg D) Sims -
1. Right Answer: A Explanation: (A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.
2. Right Answer: B Explanation: (A) Uterine contractions increase with activity. (B) Walking will increase the strength and regularity of uterine contractions in true labor. (C) Uterine contractions that are strong and regular facilitate cervical dilation. (D) Regular, strong uterine contractions, as in true labor, result in fetal descent.
3. Right Answer: A Explanation: (A) Maternal blood volume increases at the end of the first trimester leading to a dilutional anemia. (B) Maternal blood volume increases. (C) Fetal blood volume is minimal in the first trimester. (D) Increased iron absorption would facilitate the manufacturing of erythrocytes and decrease anemia.
4. Right Answer: A Explanation: (A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.
5. Right Answer: C Explanation: (A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowlers position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims position does not relieve pressure on cord or perineum.
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