NR-327 Maternal-Child Nursing - Set 3 - Part 2

Correct Answer: Nitrazine turning blue with ferning on the slide

Amniotic fluid is alkaline, so nitrazine paper shifts from yellow toward blue green, and dried fluid crystallizes into a fern pattern. Together the two results confirm that membranes have ruptured. Option a is incorrect because yellow paper means the sample stayed acidic, which describes ordinary vaginal secretions. That combination argues against rupture and would send the nurse looking for another source of wetness. Option b is incorrect because vaginal fluid normally sits between four and six on the pH scale. Finding that range simply confirms native secretions, since the amniotic sac contributes alkaline fluid instead. Option c is incorrect because scattered clumps are not the branching frond shape the test looks for. Sodium chloride and protein in amniotic fluid dry into delicate branches, not random debris.

Correct Answer: Insert a gloved hand and lift the presenting part

Lifting the presenting part off the cord with a gloved hand restores blood flow through the compressed vessels immediately, and the hand stays in place until birth because oxygenation stops within minutes otherwise. Option b is incorrect because pushing the cord back through the cervix traumatizes the vessels and triggers vasospasm, which worsens the very hypoxia being treated. Exposed cord is covered with sterile saline moistened gauze instead. Option c is incorrect because charting belongs after the fetus is stabilized. Every second spent recording details is a second the cord stays compressed, and the record can be completed once pressure has been relieved. Option d is incorrect because waiting for orders delays a nursing action the nurse may perform independently. Help is summoned while the hand elevates the presenting part, not before anyone touches the client.

Correct Answer: Report any frank bright red bleeding right away

Blood tinged mucus is the expelled operculum and a normal premonitory sign, often preceding labor within a day or two. Frank bright red bleeding is not normal and needs evaluation for previa or abruption. Option a is incorrect because bloody show alone does not mean labor has started. Admission rests on regular contractions producing cervical change, so sending her in now would likely end with a trip home. Option c is incorrect because bed rest offers no benefit here and costs her the mobility that helps labor establish itself. Walking and ordinary activity remain appropriate while she waits at home. Option d is incorrect because loss of the mucus plug usually signals labor within roughly one to two days, not weeks of ongoing discharge. Telling her to expect that would misrepresent how close she is.

Correct Answer: Turn the client onto her left side

The pregnant uterus presses the vena cava when she lies flat, cutting venous return. Rolling her to the side lifts that weight away, and blood pressure along with uteroplacental flow recovers within moments. Option a is incorrect because oxygen cannot fix a problem of blood delivery rather than blood content. Her lungs are working normally, and the obstruction sits at the vena cava under the uterus. Option b is incorrect because sitting her upright keeps the spine aligned with the great vessels and leaves the compression untouched. Only a lateral tilt or full side lying moves the uterus sideways. Option d is incorrect because a vasopressor is reserved for hypotension that persists after repositioning, most often with an epidural. Reaching for a drug first skips a free intervention that works in seconds.

Correct Answer: Frank breech with the sacrum presenting

Flexed hips with extended knees define the frank breech, the most common breech variety. The sacrum serves as the denominator, so the position code for this fetus will carry the letter S. Option a is incorrect because the complete variety keeps both hips and both knees bent, giving the cross legged sitting posture. This fetus has straight knees, which changes the description entirely. Option b is incorrect because a footling requires an extended hip with a foot pointing into the pelvis. Both hips here remain flexed, and no foot is presenting at the cervix. Option c is incorrect because vertex means the head enters first, and a military attitude describes a neutral, unflexed head. Neither term can apply when the buttocks occupy the lower uterine segment.

Correct Answer: Stay with her and summon help for birth

Crowning means birth is happening in this room. The nurse never leaves a client whose head is visible, calls for assistance, dons gloves and supports a controlled delivery of the head. Option b is incorrect because moving a client with visible scalp risks an unattended birth in the hallway. Transport belongs to earlier labor, when the presenting part has not yet reached the perineum. Option c is incorrect because paperwork can be reconstructed afterward while a birth cannot be postponed. Gathering a full history now would leave the newborn to deliver onto a stretcher unattended. Option d is incorrect because panting slows expulsive effort but does nothing about the nurse being alone. Consent for an emergency birth is implied, and no signature is worth delaying attendance.

Correct Answer: Have her breathe into her cupped hands

Fast breathing blows off carbon dioxide and produces respiratory alkalosis. Rebreathing her own exhaled air into cupped hands or a paper bag restores the carbon dioxide level and clears the tingling. Option a is incorrect because her oxygen level is already high; the problem is too little carbon dioxide. Adding more oxygen would leave the alkalosis untouched and the numbness would continue. Option b is incorrect because lying flat in labor compresses the great vessels and worsens dizziness rather than easing it. Shock positioning treats low blood volume, which is not what is happening here. Option d is incorrect because withholding fluids invites dehydration, ketosis and inefficient contractions during a long labor. Nothing about tingling fingers relates to what the client has been drinking or sipping.

Correct Answer: Turn the client onto her left side

Getting her off her back is the fastest way to restore uteroplacental blood flow, and it costs nothing. The nurse turns her while stopping the oxytocin and calling for help. Option a is incorrect because escalation happens during resuscitation rather than before it. This tracing does need urgent provider involvement, but a phone call moves no blood toward the placenta. Option b is incorrect because absent variability with recurrent lates is the most ominous combination on a strip. Waiting a quarter of an hour lets a fetus with no reserve slide further into acidemia. Option c is incorrect because oxygen belongs in the bundle but sits below positioning in the order. Perfusion has to be restored before extra oxygen content in maternal blood can reach the fetus.

Correct Answer: Continue monitoring and document the pattern

This mirror image pattern is an early deceleration caused by head compression during descent. It is benign, so the nurse simply keeps watching the strip and charts what she sees. Option a is incorrect because supplemental oxygen treats a break in the maternal side of the oxygen pathway; a vagal reflex from skull pressure involves no interruption of oxygen delivery. Option c is incorrect because lateral positioning relieves aortocaval compression or lifts the presenting part off a squeezed cord, neither of which is happening when the deceleration mirrors the contraction. Option d is incorrect because oxytocin is stopped when contractions are crowding the fetus or when the placenta cannot keep up; head compression during normal descent is not an indication.

Correct Answer: Turn the client onto her side

Turning her off her back relieves aortocaval compression and restores maternal cardiac output, which improves perfusion of the intervillous space within seconds. It is fast, independent and treats the underlying problem. Option b is incorrect because escalation belongs alongside bedside care, not ahead of it; the nurse repositions, stops the oxytocin and boluses fluid while the call is being placed. Option c is incorrect because more oxytocin shortens the resting interval the intervillous space needs to refill, deepening the very oxygen deficit that produced these decelerations. The infusion should be stopped. Option d is incorrect because watchful waiting is the response to early decelerations, which are benign. A pattern arising from a failing placenta worsens without action and demands the resuscitation bundle now.

Correct Answer: Every five minutes for the first half hour

Hypotension appears within the first ten to twenty minutes after any dose, so pressure is taken every five minutes for fifteen to thirty minutes after the initial dose and after every rebolus. Option a is incorrect because hourly readings would miss the sharp drop that typically occurs soon after a dose. By the time the next reading appeared, the fetus could already show late decelerations. Option b is incorrect because a half hour gap is the routine spacing used long after the block has settled. It is far too wide for the interval when vasodilation is still spreading. Option c is incorrect because fifteen minute checks describe the later maintenance phase once pressure has proved stable. Applying that spacing right after a rebolus delays recognition of the complication most likely to appear.

Correct Answer: Passenger and passageway, because they do not fit

Strong contractions and good flexion rule out failing powers, so an arrest with the head overriding the symphysis points to cephalopelvic disproportion, a mismatch between the size of the passenger and the passageway. Option a is incorrect because the stem already describes strong regular contractions doing their work. Adding oxytocin to a uterus that is contracting well would raise the risk of rupture without moving the head. Option b is incorrect because catecholamines from fear weaken and space out contractions, which is not what this client shows. Her uterus is performing well, so an emotional explanation cannot account for the arrest. Option d is incorrect because upright postures widen the outlet and add gravity, which helps descent instead of blocking it. Keeping her flat on her back would be the harmful choice here.

Correct Answer: The transition phase of the first stage

Irritability, nausea, trembling legs and a sense of losing control mark transition, when the cervix moves from eight to ten centimeters. Contractions come every two to three minutes and last longest. Option a is incorrect because early labor finds her chatty, excited and comfortable enough to walk the halls between mild contractions. The behavior described here belongs much later in cervical dilation. Option c is incorrect because the second stage opens only after the cervix reaches ten centimeters. Nothing in the stem says she is fully dilated, and vomiting alone does not establish that. Option d is incorrect because active pushing brings grunting, a bulging perineum and visible effort with each contraction. Shaking and irritability without an urge to bear down point to a different point in labor.

Correct Answer: Chorioamnionitis is developing and needs urgent reporting

Foul cloudy fluid with maternal fever and fetal tachycardia is intrauterine infection after prolonged rupture. Fetal tachycardia usually appears before the mother spikes, so this pattern is reported without delay. Option b is incorrect because low fluid volume raises the pulse and can nudge the temperature, but it never turns amniotic fluid cloudy or gives it a foul smell. The odor points elsewhere. Option c is incorrect because meconium tints fluid green and thickens it without producing an odor. Fetal stool also fails to explain why the mother's temperature is climbing during this labor. Option d is incorrect because healthy labor does not produce a fever, and a baseline above one hundred sixty beats per minute is outside the expected range. Calling this normal would delay antibiotics.

Correct Answer: A late deceleration from placental insufficiency

Gradual onset with the nadir arriving after the contraction peak defines a late deceleration. The lag is circulation time, and it signals that the placenta cannot meet fetal oxygen demand. Option a is incorrect because early decelerations bottom out at the same moment the contraction peaks, mirroring it exactly; the rightward shift described here rules that benign reflex out. Option b is incorrect because variables drop abruptly, reaching the nadir in under thirty seconds, and take a V or W shape with no fixed relationship to the contraction. Option d is incorrect because a prolonged deceleration lasts at least two minutes before recovering, while this dip resolves with the contraction that produced it and never reaches that length.

Correct Answer: Assess how close she is to birth

An opioid given within about an hour of birth peaks in the newborn at delivery and depresses respirations. The nurse evaluates dilation and descent, then discusses timing with the provider before anything is given. Option b is incorrect because timing the dose to a contraction lowers placental transfer only slightly. With a multipara this far along, birth may arrive inside the window when neonatal drug levels peak. Option c is incorrect because having the antagonist ready is prudent, yet preparing a rescue drug does not make an ill timed dose safe. Prevention through timing outranks reversal after the newborn is depressed. Option d is incorrect because substituting comfort measures without answering her request dismisses a legitimate need. Labor pain is not a condition to be endured on principle, and her request deserves assessment rather than deflection.

Correct Answer: Reposition the client and reduce the oxytocin

More than five contractions in ten minutes is tachysystole. With a reassuring heart rate, the nurse turns the client, gives fluid, lowers the oxytocin rate and reassesses within about fifteen minutes. Option a is incorrect because stopping the infusion outright and adding a tocolytic belongs to tachysystole accompanied by decelerations; this fetus still shows a normal baseline with moderate variability. Option c is incorrect because leaving the rate unchanged allows the intervillous space too little time to refill between contractions, and oxygen delivery falls cumulatively even while the tracing still looks normal. Option d is incorrect because surgery answers a fetus that is not tolerating labor. Here the crowded contraction pattern is iatrogenic and reverses as soon as the medication is turned down.

Correct Answer: Headache from a puncture of the dura

The positional quality identifies post dural puncture headache. Cerebrospinal fluid leaking through the dural hole lowers intracranial pressure, so upright posture pulls on pain sensitive structures and lying flat relieves the traction. Option a is incorrect because a preeclamptic headache persists in every position and travels with hypertension, visual changes, or epigastric pain. A headache that vanishes when she lies down points away from that diagnosis. Option b is incorrect because missing coffee produces a dull generalized ache unrelated to posture. Caffeine actually appears here as part of the treatment, not as the cause of what she is describing. Option c is incorrect because infection of the meninges brings fever, neck stiffness, and a steadily worsening course rather than instant relief on lying down. Site redness or drainage would usually accompany it.

Correct Answer: Maternal hypotension from sympathetic nerve blockade

Sympathetic fibers block first and spread several dermatomes above the sensory level, so vasodilation drops venous return and cardiac output. Hypotension is therefore the most common epidural complication, usually within the first twenty minutes. Option b is incorrect because blood pressure falls rather than rises after the block. Epidural analgesia actually blunts the catecholamine surge of painful labor, which is one reason it is offered in hypertensive disorders. Option c is incorrect because a post dural puncture headache follows accidental entry through the dura, an uncommon event, and it usually appears a day or more later rather than during dosing. Option d is incorrect because systemic toxicity from local anesthetic requires the drug to enter a vein directly. Catheter aspiration and a test dose are performed precisely to make that rare event even rarer.

Correct Answer: Notify anesthesia and the provider immediately

A block that deepens after it should be resolving, with severe back pain and new weakness, suggests an epidural hematoma compressing the cord. Urgent imaging and decompression prevent permanent paraplegia, so escalation cannot wait. Option a is incorrect because an hour of watching is exactly what turns a treatable compression into permanent paralysis. Any new or worsening neurologic deficit after a block is escalated at once. Option c is incorrect because walking a client whose legs are failing invites a fall and delays diagnosis. Weakness appearing hours after the infusion stopped is not deconditioning that exercise will reverse. Option d is incorrect because heat soothes ordinary muscular soreness at the insertion site, which resolves over days. It offers nothing against bleeding inside the spinal canal and masks the urgency of her symptoms.