Maternal Newborn Nursing The Critical Components Of Nursing Care 2nd Edition by Roberta Durham – Test Bank

Chapter 11: Intrapartum and Postpartum Care of Cesarean Birth Families

Multiple Response

1. Which of the following is a medical indication for a cesarean birth? (Select all that apply.)
a. Maternal blood pressure of 130/90b. Cervical dilation of 1.5 cm per hour during the active phase of laborc. Late deceleration of the fetal heart rate with minimal variabilityd. Complete placenta previae. Arrest of fetal descent

ANS: c, d, eA maternal blood pressure of 130/90 may be an indication of mild PHI which is not a medical indication for cesarean birth. Cervical dilation of 1.5 cm/minutes is within normal limits for cervical changes during the active phase. Late decelerations combined with minimal variability in the fetal heart rate reflect fetal intolerance of labor and are an indication for cesarean birth. A complete placenta previa covers the internal os necessitating a cesarean birth. Arrest of fetal descent indicates cephalopelvic disproportion.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

2. A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor and operative records indicate that she had premature rupture of membranes followed by 36 hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is 1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that apply.)
a. Fluid volume deficitb. Infectionc. Impaired mother–infant attachmentd. Falls

ANS: a, b, c, dThe woman is at risk for fluid volume deficit related to blood loss and risk for postpartum hemorrhage due to risk of uterine atony. She is at risk for infection related to premature and prolonged rupture of membranes. The woman is at risk for impaired mother–infant attachment related to maternal pain and exhaustion. She is at risk for falls related to anesthesia and orthostatic hypotension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

3. The perinatal nurse teaches the student nurse that deep breathing exercises following a cesarean birth are critical to the prevention of (select all that apply):
a. Pneumonia
b. Atelectasis
c. Abdominal distension
d. Increased tidal volume

ANS: a, b
Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

Multiple Choice

4. A nurse is admitting a woman for a scheduled cesarean section. Which of the following assessment data should be immediately reported to the physician?a. White cell count of 11,000b. Hemoglobin of 11 g/dLc. Hematocrit of 33%d. Platelet count of 97,000

ANS: d
Feedback
a. This laboratory value is within normal limits for a pregnant woman.
b. This laboratory value is within normal limits for a pregnant woman.
c. This laboratory value is within normal limits for a pregnant woman.
d. Normal range of platelets is 150,000 to 400,000. A low platelet count places the woman at risk for increased bleeding.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Reduction of Risk Potential
Difficulty Level: Moderate

5. A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couple’s anxiety levels.a. Explain the reason for the need for a cesarean section.b. Inform parents that their baby is in distress.c. Ask the couple to share their concerns.d. Reassure the couple that both the woman and baby are in no danger.

ANS: c
Feedback
a. Explaining the reason she is having a cesarean birth is helpful but may not address their concerns.
b. It is important to acknowledge that the baby is stable, but this response does not allow the couple to share their concerns that may be causing an increase in anxiety.
c. By asking the couple to share their concerns, the nurse can address these concerns.
d. Reassuring the couple that the woman and baby are in no danger is correct, but it is not the best answer because it does not allow the couple to verbalize their concerns.

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

6. A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention?a. Itching of the palms and feetb. Nauseac. Urinary output of 300 mL in the past 4 hoursd. Respiratory rate of 10 breaths/minute

ANS: d
Feedback
a. This is a side effect of intrathecal morphine which is not life threatening.
b. This is a side effect of intrathecal morphine which is not life threatening.
c. A urinary output of 300 mL in 4 hours is within normal limits.
d. Correct. An adverse effect of intrathecal morphine that requires immediate intervention is respiratory distress.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Reduction of Risk Potential |Difficulty Level: Moderate

7. A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time?
a. Maintain the client flat in bed.
b. Assess the client’s patellar reflexes.
c. Monitor hourly urinary outputs.
d. Assess the client’s respiratory rate.

ANS: d
Feedback
a. The client should be assisted to a position of comfort.
b. There is no indication in the scenario that the client must have her reflexes assessed.
c. The client’s hydration should be monitored postsurgery, but hourly assessments are unnecessary.
d. The client has undergone major abdominal surgery. Her respiratory function should be assessed regularly.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Postpartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate

8. A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see?
a. Abdominal distension
b. Polyuria
c. Diastasis recti
d. Dependent edema

ANS: a
Feedback
a. The nurse would expect to see a distended abdomen in a client with a paralytic ileus.
b. Polyuria is unrelated to a paralytic ileus.
c. Diastasis recti is unrelated to a paralytic ileus.
d. Dependent edema is unrelated to a paralytic ileus.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Physiological Adaptation: Alterations in Body Systems; Postpartum Care | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Moderate

9. The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse:
a. Assists the woman to lie down in a supine position.
b. Administers a rapid intravenous infusion of 500 mL of normal saline.
c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion.
d. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.

ANS: b
Complications that may occur with spinal anesthesia block include maternal hypotension, decreased placental perfusion, and an ineffective breathing pattern. Prior to administration, the patient’s fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities). Following administration of the anesthetic, the patient’s blood pressure, pulse, and respirations and fetal heart rate must be taken and documented every 5 to 10 minutes.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

10. The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic agent in an epidural is primarily to:
a. Increase the total anesthetic volume
b. Preserve a greater amount of maternal motor function
c. Increase the intensity of the motor and sensory block
d. Decrease the number of side effects

ANS: b
Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required and helps to preserve a greater amount of maternal motor function.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult