Name: Rou’z Ven E.

Semilla BSN -A1 Date: 11-28-2021

NURSING SEMINAR
SAS NUMBER 2
CHECK FOR UNDERSTANDING (25 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed. You are given 25 minutes for this activity:

1. A nurse in a labor room is monitoring a client with dysfunctional labor signs of fetal or maternal compromise.
Which of the following assessment findings would alert the nurse to a compromise?
a. Persistent non-reassuring fetal heart rate
b. Maternal fatigue
c. Progressive changes in the cervix
d. Coordinated uterine contractions
Answer: A
Rationale: Signs of maternal or fetal compromise include passage of meconium decreased movement felt by the
mother, non-reassuring fetal heart rate and fetal metabolic acidosis. Maternal fatigue and infection can occur if
the labor is prolonged, but do not indicate fetal or maternal compromise. Progressive changes in the cervix and
coordinated uterine contractions are a reassuring pattern in labor.

2. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The
nurse is reviewing the physician’s orders and would expect to note which of the following prescribed
treatments for this condition?
a. Medication that will provide sedation
b. Increased hydration
c. oxytocin (Pitocin) infusion
d. Administration of a tocolytic medication

Answer: C
Rationale: The clinical management for hypotonic uterine dysfunction includes oxytocin augmentation and
amniotomy to stimulate a labor that slows. Oxytocin  stimulates the uterine muscles to contract  and also increases
production of prostaglandins, which increase the contractions further.

3. A nurse in a labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told
that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration and
intensity. The priority nursing intervention in caring for the client is to:
a. Monitor the oxytocin (Pitocin) infusion closely
b. Provide pain relief measures
c. Prepare the client for an amniotomy
d. Promote ambulation every 30 min

Answer: B

Rationale: Hypertonic uterine contractions are described as painful, they occur frequently, and are uncoordinated.
The clinical management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to
promote a normal labor pattern. An amniotomy and oxytocin infusions are not treatment measures for hypertonic
contractions instead, it is used for hypotonic contractions.

4. A nurse is providing emergency measures to a client in labor who has been diagnosed with prolapsed cord.
The mother becomes anxious and frightened and says to the nurse, “Why are all of these people in here? Is
 my baby going to be alright?” Which of the following nursing diagnoses would be most appropriate for the
client at this time?
a. Fear
b. Powerlessness
c. Ineffective individual coping
d. Sensory overload
Answer: A
Rationale: The mother or the patient feels fear in what is currently happening

5. A nurse has developed a plan of care for a client experiencing dystocia and includes several nursing
interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following
nursing interventions as the highest priority?
a. Keeping the significant other informed of the progress of labor
b. Providing comfort measures
c. Monitoring the fetal heart rate
d. Changing the client’s position frequently.

Answer: C

Rationale: The priority in the plan of care would include the intervention that addresses the physiological integrity
of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the
significant other informed of the progress of the labor are components of the plan of care, fetal status is the
priority.

6. A clinic nurse is performing a prenatal assessment on a pregnant client. The nurse would implement teaching
related to the risk of abruptio placentae if which of the following information was obtained on assessment?
a. The client has a history of hypertension
b. The client performs moderate exercise on a regular daily schedule
c. The client is 28 years of age
d. This is the second pregnancy

Answer: A

Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th
week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized
by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse.

7. A nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive.
Which assessment finding would indicate that the client is at risk of preterm labor?
a. The client is a 35-year-old primigravida
b. The client is a 20-year-old primigravida of average weight and height
c. The client’s hemoglobin level is 13.5 g/dl
d. The client has a history of cardiac disease

Answer: D
Rationale: Preterm labor happens after the twentieth week of pregnancy but before the 37th week. A history of
medical disorders, current and previous obstetric difficulties, social and environmental variables, and drug
addiction are all linked to premature labor.
8. A nurse is caring for a client in labor. The nurse documents that the client is beginning the second stage of
labor when which of the following assessments is noted?
a. The client begins to expel clear vaginal fluid
b. the contractions are regular
c. the membranes have raptured
d. the cervix is completely dilated

Answer: D
Rationale: The second stage of labor begins when the cervix is dilated completely and ends with the birth of the
neonate.

9. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment
finding would indicate a need to contact the physician?
a. Fetal heart rate of 180 beats per minute
b. White blood cell (WBC) count of 12,000/mm3
c. Maternal pulse rate of 85 beats per minute
d. Hemoglobin of 11.0 g/dl

Answer: A
Rationale: A fetal heart rate of 120-160 beats per minute is considered normal. A fetal heart rate of 180 beats per
minute may suggest fetal discomfort and should be reported to a doctor. Because of the hemodilution generated
by an increase in plasma volume during pregnancy, a typical maternal hemoglobin range by full term is 11-13 g/dL.

10. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by cesarean
delivery. Which statement if made by the client indicates a need for further education?
a. “I will notify the physician if I develop a fever.”
b. ” I will lift nothing heavier than the newborn infant for at least 2 weeks.”
c. “I will begin abdominal exercises immediately. “
d. “I will turn on my side and push up with my arms to get out of bed.”

Answer: C
Rationale: An incision through the abdominal wall and into the uterus is required for a cesarean birth. Abdominal
workouts should not be started right after abdominal surgery; the client should wait at least three to four weeks
for the wound to heal. After a cesarean birth, options 2, 3, and 4 are suitable instructions for the client.

11. A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate
uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be
discontinued?
a. Three contractions occurring within a 10-minute period
b. A fetal heart rate of 90 beats per minute
c. Adequate resting tone of the uterus palpated between contractions
d. Increased urinary output

Answer: B
Rationale: The heart rate of a fetus should be between 120 and 160 beats per minute. Bradycardia or late or varied
decelerations are signs of fetal distress, and Pitocin should be stopped. Three good-quality contractions in a 10-
minute interval is the objective of labor augmentation.
12. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 min that
lasts 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per min. Which
of the following nursing actions is most appropriate?
a. Encourage the client’s coach to continue to encourage breathing techniques
b. Encourage the client to continue pushing with each contraction
c. Continue monitoring the fetal heart rate
d. Notify the physician or nurse-midwife

Answer: D
Rationale: A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may
indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified.

13. A post-partum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the
immediate post-partum period, the nurse plans to take the woman’s vital signs:
a. Every 30 min during the first hour and then every hour for the next 2 hours
b. Every 15 min during the first hour and then every 30 min in the next 2 hours
c. Every hour for the first 2 hours and then every 4 hours
d. Every 5 min for the first 30 min and then every hour for the next 4 hours

Answer: B
Rationale: During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour
after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors
vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

14. A post-partum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago.
The nurse notes that the mother’s temperature is 100.2F. Which of the of the following would be most
appropriate?
a. Retake the temperature in 15 min
b. Notify the physician
c. Document the findings
d. Increase hydration by encouraging oral fluids

Answer: D
Rationale: The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F
(38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action
is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading.
Although the nurse also would document the findings, the appropriate action would be to increase hydration.
Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

15. A nurse is assessing a client who is 6 hours postpartum after delivering a full term healthy newborn infant. The
client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions
would be most appropriate?
a. Obtain hemoglobin and hematocrit levels
b. Instruct the mother to request help when getting out of bed
c. Elevate the mother’s legs
d. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of
lightheadedness and dizziness have subsided
Answer: B
Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or
dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the
client to get help the first few times she gets out of bed.
16. A nurse is preparing to perform a fundal assessment on a post-partum client. The initial nursing action in
performing this assessment is which of the following?
a. Ask the client to turn on her side
b. Ask the client to lie flat on her back with the knees and legs flat and straight
c. Ask the mother to urinate an empty her bladder
d. Massage the fundus gently prior to determining the level of the fundus

Answer: C
Rationale: Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an
accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately
assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the
knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be
massaged gently until firm.

17. A nurse is caring for a postpartum woman who has received epidural anesthesia and is monitoring the woman
for the presence of a vulvar hematoma. Which of the following assessment findings would best indicate the
presence of a hematoma?
a. Complaints of a tearing sensation
b. Complaints of intense pain
c. Changes in vital signs
d. Signs of heavy bruising

ANSWER: C
RATIONALE: Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or
a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar
hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood
polling.

18. A nurse is developing a plan of care for a postpartum woman with a small vulvar hematoma. The nurse
includes which specific intervention in the plan for this client?
a. Assess vital signs every 4 hours
b. Inform health care provider of assessment findings
c. Measure fundal height every 4 hours
d. Prepare an ice pack for application to the area.
ANSWER: D
RATIONALE: A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery.
Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the
vulvar area.

19. A new mother received an epidural during labor and had a forceps delivery after pushing for 2 hours. At 6
hours post- partum, her systolic blood pressure has dropped 20 points, her diastolic blood pressure has
dropped 10 points and her pulse is 12 beats per min. The client is very anxious and restless. Upon further
assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately
plans to
a. Monitor fundal height
b. Apply perineal pressure
c. Prepare the client for surgery
d. Reassure the client

ANSWER: C
RATIONALE: A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A
vulvar hematoma is the most common type. The use of an epidural, prolonged second-stage labor, and forceps
delivery are predisposing factors for hematoma formation, and a collection of up to 500 mL of blood can occur in
the vaginal area. Although the other options may be implemented, the immediate action is to prepare the client
for surgery to stop the bleeding.

20. After surgical evacuation and repair of paravaginal hematoma, the 3-day post-partum mother is discharged. A
nurse knows that the new mother needs further discharge instructions when the new mother states:
a. “Because I am so sore, I will nurse the baby while being on my side.”
b. “I will probably need my mother to help me with housekeeping
c. “My husband and I will not have intercourse until the stitches are healed.”
d. “The only medication I will take are prenatal vitamins and stool softeners.”

Answer: D
Rationale: The post-operative patient will requires an antibiotic is due to that fact that she is at increased risk for
infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will
need only prenatal vitamins and stool softeners indicates that she requires further teaching.