Chapter 23 Maternal and Child Health Nursing 7th Edition

Chapter 23  Maternal and Child Health Nursing 7th Edition

Complete Chapter Questions And Answers
 

Sample Questions

1.
A pregnant patient in labor is having contractions 2 minutes apart but rarely over 50 mmHg in strength; the resting tone is high, 20 to 25 mmHg. The patient asks what can be done to make contractions more effective. What should the nurse respond to the patient?
A)
Rest because contractions are hypertonic.
B)
Receive oxytocin to strengthen contractions.
C)
Hypotonic contractions of this kind will strengthen by themselves.
D)
Walking around will make the contractions more regular.
Ans:
A

Feedback:

A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. The best intervention is to encourage the patient to rest between contractions. Oxytocin will not help strengthen hypertonic contractions. Walking will not help make the contractions more regular. These are hypertonic and not hypotonic contractions.

2.
A patient in labor has been prescribed an intravenous infusion of 5% dextrose/water. Following insertion of the intravenous line, what should the nurse instruct the patient to do?
A)
Try to forget the fluid line is in place.
B)
Lie on the back to allow optimal flow.
C)
Not to get out of bed once the needle is in place.
D)
Lie perfectly still so as not to dislodge the needle.
Ans:
A

Feedback:

Many patients react negatively to the idea of IV fluid therapy during labor to restore body fluid. Assure the patient that being out of bed and walking, turning freely, squatting, sitting, or using whatever position preferred during labor will not disrupt the IV line or the infusion. The nurse should not tell the patient to lie on the back or to lie perfectly still. The patient should also be encouraged to get out of bed if that is permitted and desired by the patient in labor.

3.
A patient in labor has reached 8 cm dilation, but the fetal heart rate suddenly slows. Perineal inspection reveals a prolapsed fetal cord. What should the nurse do first?
A)
Turn the patient onto the left side.
B)
Replace the cord with gentle pressure.
C)
Place the patient in a knee–chest position.
D)
Cover the exposed cord with a dry, sterile wrap.
Ans:
C

Feedback:

Prolapsed cord is always an emergency situation because the pressure of the fetal head against the cord at the pelvic brim leads to cord compression and decreased oxygenation to the fetus. Pressure on the cord must be relieved, which is done by placing the patient in a knee–chest or Trendelenburg position to cause the fetal head to fall back from the cord. Turning the patient onto the left side will not relieve pressure on the fetal cord. Any amount of prolapsed cord should not be reinserted into the patient. Exposed cord should be covered with sterile saline compresses to prevent drying.

4.
A pregnant patient is prescribed to have labor induced with oxytocin. How should the nurse prepare to administer this medication?
A)
In a 20-cc bolus of saline
B)
In two divided intramuscular sites
C)
Diluted as a “piggyback” infusion
D)
Diluted in the main intravenous fluid
Ans:
C

Feedback:

When administering oxytocin, the infusion should be “piggybacked” to a maintenance IV solution and add the piggyback to the main infusion at the port closest to the patient. If the oxytocin needs to be discontinued quickly during the induction, little solution remains in the tubing to still infuse, and the main IV line can still be maintained. Oxytocin is not administered as an intravenous bolus, as intramuscular injections, nor is it diluted in the main intravenous fluid.

5.
After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting. What should the nurse do?
A)
Assess the vagina for full dilation.
B)
Notify the physician and stop the infusion.
C)
Instruct the patient to breathe in and out rapidly.
D)
Administer oral orange juice for added potassium.
Ans:
B

Feedback:

A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. This is first manifested by headache and vomiting. If these danger signs are observed in the patient during induction of labor, report them immediately and halt the infusion. Assessing the vagina for dilation, increasing respirations, and administering orange juice for potassium will not help with water intoxication.