Maternal Monitoring

Maternal Monitoring Related

Review Maternal Monitoring related questions and content

The nurse who will care for a patient in labor receives a report and is told that the patient's status is as follows: 4 cm, 50%, and +1 station. What should be the nurse's interpretation of this information?

  • A. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm below the ischial spines.
  • B. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm above the ischial spines.
  • C. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm below the ischial spines.
  • D. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm above the ischial spines.
Correct Answer: C

Rationale: The correct interpretation is C because in labor progress, cervical dilation (4 cm) refers to how much the cervix has opened, effacement (50%) indicates the thinning of the cervix, and station (+1) describes the descent of the baby's head in relation to the ischial spines. Therefore, the nurse should understand that the cervix is dilated 4 cm, effaced 50%, and the baby's head is 1 cm below the ischial spines, which is indicative of progressing labor.

Choice A is incorrect because it incorrectly describes the station as being 1 cm below the ischial spines instead of above. Choice B is incorrect as it inaccurately states that the cervix is effaced to 50% rather than dilated. Choice D is incorrect because it states that the cervix is effaced 4 cm, which is not a correct representation of effacement.

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A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?

  • A. Magnesium sulfate
  • B. Prostaglandin suppository
  • C. RhoGAM if the patient is Rh-negative
  • D. Betamethasone
Correct Answer: C

Rationale: Rh-negative women undergoing CVS require RhoGAM to prevent Rh sensitization.

A client asks the nurse what was meant when the physician told her she had a positive Chadwick’s sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time?

  • A. It is a purplish stretch mark on your abdomen.
  • B. It means that you are having heart palpitations.
  • C. It is a bluish coloration of your cervix and vagina.
  • D. It means the doctor heard abnormal sounds when you breathed in.
Correct Answer: C

Rationale: Chadwick’s sign is a bluish coloration of the cervix and vagina due to increased blood flow, which is a common early sign of pregnancy.

A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?

  • A. verify the person's immunization history
  • B. obtain informed consent
  • C. check for signs of an allergic reaction
  • D. ensure proper positioning for the vaccine
Correct Answer: D

Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.

A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?

  • A. Instruct the patient to avoid standing for long periods.
  • B. Encourage the patient to increase sodium intake.
  • C. Recommend that the patient take frequent naps during the day.
  • D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D

Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.

A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.

The nurse is caring for a pregnant patient who is 37 weeks gestation and is experiencing contractions every 10 minutes. Which of the following should the nurse assess first?

  • A. The patient's vital signs and fetal heart rate
  • B. The patient's cervical dilation and effacement
  • C. The patient's urinary output and fluid balance
  • D. The patient's emotional status and support system
Correct Answer: B

Rationale: The correct answer is B: The patient's cervical dilation and effacement. At 37 weeks gestation with contractions every 10 minutes, assessing cervical dilation and effacement is crucial to determine if the patient is in active labor. This information will guide the nurse in determining the appropriate next steps for the patient's care, such as the need for further monitoring or interventions. Assessing vital signs and fetal heart rate (Choice A) is important but not the priority in this scenario. Urinary output and fluid balance (Choice C) are important considerations but not the immediate priority. Emotional status and support system (Choice D) are also important but not the first assessment to be made in this situation.

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