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What is the best response?
- A. The fundus is not assessed until the second postoperative day.
- B. The fundus is assessed by 'walking' fingers from the side of the uterus to the midline.
- C. The fundus is assessed only if large clots appear in lochia.
- D. The fundus is assessed only once every shift.
Correct Answer: B
Rationale: Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.
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Which statement indicates a woman understands activity limitations for the management of preterm labor?
- A. After my shower in the morning, I do the laundry and straighten up the house; then I rest.'
- B. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.'
- C. I have a 2-year-old to care for, but I try to rest as much as I can.'
- D. I get really bored at home, so I go to the shopping mall for just a little while.'
Correct Answer: B
Rationale: Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.
Which laboring patient should the nurse attend to first?
- A. 18-year-old primigravida with a fetal breech presentation
- B. 25-year-old multigravida with history of previous cesarean section
- C. 35-year-old multigravida with history of precipitate birth
- D. 16-year-old primigravida with a twin pregnancy
Correct Answer: C
Rationale: A precipitate birth is completed in less than 3 hours and can lead to complications like uterine rupture or cervical lacerations, requiring immediate attention.
What is the best nursing action?
- A. Give the pain remedy.
- B. Notify the charge nurse immediately.
- C. Turn the patient to her back and flex her knees.
- D. Suggest that the coach give her a back rub.
Correct Answer: B
Rationale: Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.
What conditions would contraindicate labor induction?
- A. Maternal gynecoid pelvis
- B. Placenta previa
- C. Horizontal cesarean incision
- D. Prolapsed cord
- E. Gestational diabetes
Correct Answer: B,D
Rationale: Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord.
What sign(s) of infection should the nurse assess for after an amniotomy?
- A. Oral temperature of 37?°C (99.8?°F)
- B. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute
- C. Flecks of vernix in the amniotic fluid
- D. Low back pain
Correct Answer: B
Rationale: Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation, indicating possible infection.