Question 139571

Id:

139571

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The nurse is scheduling a patient for an external cephalic version (ECV). Which finding in the patients chart
requires immediate intervention?
Stimulus

Answer
Choice 1

Multip, transverse lie.

Rationale 1

This patient has no contraindication to ECV.

Answer 1

false

Choice 2

Primip, frank breech ballotable.

Rationale 2

This patient has no contraindication to ECV.

Answer 2

false

Choice 3

Multip, 32 weeks, complete breech.

Rationale 3

ECV is not attempted until 36 weeks. This patient is too early in her
pregnancy for ECV.

Answer 3

true

Choice 4

Primip, failed ECV last week.

Rationale 4

Although this patient is less likely to have a successful ECV this week if it
was unsuccessful last week, there is no contraindication to attempting the
procedure.

Answer 4

false

Global Rationale

Meta 1

Cognitive Level:

Applying

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Implementation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO01_Q01

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:

Meta 4

admin

Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO01 - Explain the methods, purpose, criteria, and contraindications of

external and podalic versions that determine nursing care management.

Question 139572
Id:

139572

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The clinical nurse coordinator is meeting with a group of nursing students in post conference to teach about
caring for women who undergo artificial rupture of membranes (AROM) by way of amniotomy. Which
nursing students statement indicates that the teaching has been effective?
Stimulus

Answer
Choice 1

For women who undergo artificial rupture of membranes, vaginal

examinations should be limited.

Rationale 1

Following artificial rupture of membranes (AROM), because there is now an

open pathway for organisms to ascend into the uterus, the number of vaginal
exams must be kept to a minimum to reduce the chance of introducing an
infection.

Answer 1

true

Choice 2

In most cases, it is appropriate to assess the fetal heart rate (FHR) right after
the artificial rupture of membranes is performed.

Rationale 2

In all cases, the fetal heart rate (FHR) is assessed just before and
immediately after the amniotomy, and the two FHR assessments are
compared.

Answer 2

false

Choice 3

Amniotomy is contraindicated for use in labor augmentation.

Rationale 3

Amniotomy is an accepted method of labor augmentation.

Answer 3

false

Choice 4

Women who undergo artificial rupture of membranes should be advised that

they will experience a dry birth.

Rationale 4

Women need to know that amniotic fluid is constantly produced because

some women may worry that they will experience a dry birth.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Understanding

Client Need:

Physiological Integrity

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Planning

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO03 _Q02

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:

admin

Stakes:
Special Handling:
Comments:

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO02- Describe the use of amniotomy and the nursing care management of
the woman and fetus.

Question 139573
Id:

139573

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
Induction of labor is planned for a 31-year-old primip due to insulin-dependent diabetes. The patient is 39
weeks gestation. She reports that she feels as though her baby has flipped in her abdomen. Which nursing
action is most important?
Stimulus

Answer
Choice 1

Evaluate fetal maturity.

Rationale 1

Malpresentation, such as breech, is a relative contraindication to induction of

labor. Before proceeding with preparation for induction of labor, the patient
will require additional evaluation by her physician before proceeding.

Answer 1

false

Choice 2

Administer dinoprostone (Prepidil ) vaginal gel.

Rationale 2

Malpresentation, such as breech, is a relative contraindication to induction of

labor. Before proceeding with preparation for induction of labor, the patient
will require additional evaluation by her physician before proceeding.

Answer 2

false

Choice 3

Implement continuous electronic fetal monitoring (EFM).

Rationale 3

Malpresentation, such as breech, is a relative contraindication to induction of

labor. Before proceeding with preparation for induction of labor, the patient
will require additional evaluation by her physician before proceeding.

Answer 3

false

Choice 4

Notify the patients physician that the patient feels as though her baby has
changed position.

Rationale 4

Because malpresentation, such as breech, is a relative contraindication to

induction of labor, the patient will require additional evaluation by her
physician before proceeding.

Answer 4

true

Global Rationale

Meta 1
Cognitive Level:

Understanding

Client Need:

Physiological Integrity

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Evaluation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO02_Q03

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:

admin

Stakes:
Special Handling:
Comments:

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO03 Compare the for inducing labor, explaining their advantages and
disadvantages in determining the nursing management for women during
labor induction.

Question 139575
Id:

139575

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The nurse is completing discharge teaching for a patient who delivered two days ago. Which statement
indicates that further information is required?
Stimulus

Answer
Choice 1

Because I have a midline episiotomy, I should keep my perineum clean.

Rationale 1

Perineal hygiene is important when a patient has an episiotomy to prevent

infection and facilitate healing.

Answer 1

false

Choice 2

Soaking in the tub will help my mediolateral episiotomy to heal.

Rationale 2

Warm tub baths are helpful to facilitate both comfort and healing of an
episiotomy.

Answer 2

false

Choice 3

I can take ibuprofen (Motrin) when my perineum starts to hurt.

Rationale 3

Healing episiotomies can be very painful, and pain medication should be

provided for patients experiencing pain.

Answer 3

false

Choice 4

The tear I have through my rectum is unrelated to my episiotomy.

Rationale 4

This statement is incorrect. Midline episiotomies tend to tear posteriorly

toward the rectum.

Answer 4

true

Global Rationale

Meta 1
Cognitive Level:

Analyzing

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Evaluation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO05_Q05

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:

admin

Comments:

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO04 Describe the measures to prevent episiotomy, and the types of

episiotomy and associated nursing care management.

Question 139576
Id:

139576

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The patient requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts
a mediolateral episiotomy. After delivery, the patient asks what kind of episiotomy was performed. What is the
best response for the nurse to make? The episiotomy:
Stimulus

Answer
Choice 1

Goes straight back toward your rectum.

Rationale 1

Midline episiotomy is straight back from the vagina toward the rectum.

Answer 1

false

Choice 2

Is from your vagina toward the urethra.

Rationale 2

Episiotomies are not cut anteriorly toward the urethra unless the patient has
had a female circumcision.

Answer 2

false

Choice 3

Is cut diagonally away from your vagina.

Rationale 3

Mediolateral episiotomy is angled from the vaginal opening toward the

buttock.

Answer 3

true

Choice 4

Extends from your vagina into your rectum.

Rationale 4

Extension into the rectum is a fourth-degree laceration.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Applying

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Implementation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO05_Q06

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:

Meta 4

admin

Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO04 Describe the measures to prevent episiotomy, and the types of

episiotomy and associated nursing care management.

Question 139577
Id:

139577

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The patient is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and
sore. The patient is asking for her ice pack to be refreshed. The best response from the nurse is:
Stimulus

Answer
Choice 1

Ill get you one right away.

Rationale 1

Providing an additional ice pack before 20 minutes have passed would

increase the perineal edema.

Answer 1

false

Choice 2

You only need to use one ice pack.

Rationale 2

More than one ice pack must be used in order to apply ice for 20 minutes on,
followed by 20 minutes off.

Answer 2

false

Choice 3

You need to leave it off for at least 20 minutes and then reapply.

Rationale 3

Optimal effects from the use of an ice pack occur when it is applied for 20
30 minutes and then removed for at least 20 minutes before being reapplied.

Answer 3

true

Choice 4

Ill bring you an extra so that you can change it when you are ready.

Rationale 4

An ice pack that is provided now for use in 20 minutes would be melted
before being used.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Applying

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Implementation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO05_Q07

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:

admin

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO04 Describe the measures to prevent episiotomy, and the types of

episiotomy and associated nursing care management.

Question 139578
Id:

139578

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring patient who is
undergoing a forceps delivery. Which action requires intervention?
Stimulus

Answer
Choice 1

Regional anesthesia is administered via pudendal block.

Rationale 1

Regional anesthesia is important to facilitate application of the forceps and

cooperation with pushing efforts.

Answer 1

false

Choice 2

The patient is instructed to push between contractions.

Rationale 2

The patient should only push during contractions, not between contractions.

Answer 2

true

Choice 3

Fetal heart tones are consistently between 110 and 115.

Rationale 3

These are normal fetal heart tones. No intervention is needed.

Answer 3

false

Choice 4

Bladder is emptied using a straight catheter.

Rationale 4

The urinary bladder is emptied to prevent the full bladder from impeding
descent of the fetal head.

Answer 4

false

Global Rationale

Meta 1

Cognitive Level:

Applying

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Planning

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO06_Q08

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:

Meta 4

admin

Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO05 - Explain the indications, maternal and neonatal risks that impact
nursing care management during forceps-assisted birth.

Question 139579
Id:

139579

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The patient has been pushing for two hours and is exhausted. The physician is performing a vacuum extraction
birth. What finding is expected?
Stimulus

Answer
Choice 1

The head is delivered after eight pulls during contractions.

Rationale 1

Use of the vacuum extraction for eight contractions is too many and can
create damage to the fetal head. If fetal descent does not occur with the first
two pulls, the procedure should be discontinued, and cesarean birth should
take place.

Answer 1

false

Choice 2

A bruise is present on the occiput that does not cross the suture line.

Rationale 2

This is a cephalohematoma and is a complication of vacuum extraction birth.

Answer 2

false

Choice 3

The location of the vacuum is apparent on the fetal scalp after birth.

Rationale 3

Caput in the shape of the vacuum cup is usually present immediately after
birth and resolves in 23 days.

Answer 3

true

Choice 4

Positive pressure is applied by the vacuum extraction during contractions.

Rationale 4

Negative pressure is suction, which is needed to use the vacuum extractor to

facilitate birth.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Applying

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Assessment

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO07_Q09

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:

admin

Comments:

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO06 - Describe the use of and risk of vacuum extraction use to assist birth.

Question 139580
Id:

139580

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The patient has been pushing for two hours and is exhausted. The fetal head is visible between contractions.
The physician informs the patient that a vacuum extractor could be used to facilitate the delivery. Which
statement indicates that the patient needs additional information about vacuum extraction assistance?
Stimulus

Answer
Choice 1

A small cup will be put onto the babys head, and a gentle suction will be
applied.

Rationale 1

The vacuum extractor is a small cup-shaped device that is applied to the

scalp.

Answer 1

false

Choice 2

I can stop pushing and just rest if the vacuum extractor is used.

Rationale 2

Vacuum extraction is an assistive delivery, and the patient must continue

with pushing efforts to accomplish the birth.

Answer 2

true

Choice 3

The babys head might have a bruise from the vacuum cup.

Rationale 3

The vacuum extractor might leave a bruise on the scalp where the device is
placed.

Answer 3

false

Choice 4

The vacuum will be applied for a total of ten minutes or less.

Rationale 4

The vacuum extractor is applied to the scalp for up to 10 minutes total.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Analyzing

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Evaluation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO07_Q10

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:

admin

Comments:

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO06 - Describe the use of and risk of vacuum extraction use to assist birth.

Question 139581
Id:

139581

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The nurse is reviewing charts of patients who underwent cesarean births by request in the last two years. The
hospital is attempting to decrease costs of maternity care. What findings contribute to increased healthcare
costs in patients undergoing cesarean birth by request?
Stimulus

Answer
Choice 1

Increased abnormal placenta implantation in subsequent pregnancies

Rationale 1

Placenta implantation problems are more common after cesarean birth and
increase healthcare costs because of the high risk care and testing required.

Answer 1

true

Choice 2

Decreased use of general anesthesia with greater use of epidural anesthesia

Rationale 2

Which anesthesia method is used is not a significant factor in health care

costs of cesarean birth by request. The need for anesthesia, use of the
operating suite, equipment use, personnel, and other factors are more
responsible for greater costs of cesarean birth compared with vaginal birth.

Answer 2

false

Choice 3

Prolonged anemia, requiring blood transfusions every few months

Rationale 3

This is not a complication of cesarean birth by request.

Answer 3

false

Choice 4

Coordination of career projects of both partners leading to increased income

Rationale 4

The income of the couple does not affect healthcare costs directly.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Applying

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Assessment

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO08_Q11

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:

admin

Comments:

Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO07 - Explain the indications for cesarean birth, impact on the family unit,
preparation and teaching needs, and associated nursing care.

Question 139582
Id:

139582

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The patient had a classical uterine incision for her cesarean birth. The nurse knows that the patient understands
implications for future pregnancies that are secondary to her classical uterine incision when the patient states:
Stimulus

Answer
Choice 1

The next time I have a baby, I can try to deliver vaginally.

Rationale 1

Attempting a vaginal birth is contraindicated, and future births will be

planned cesareans.

Answer 1

false

Choice 2

The risk of rupturing my uterus is too high for me to have any more
babies.

Rationale 2

Future pregnancies are not prohibited.

Answer 2

false

Choice 3

Every time I have a baby, I will have to have a cesarean delivery.

Rationale 3

A classical uterine incision is made in the upper uterine segment and holds
an increased risk of rupture in subsequent pregnancy, labor, and birth.

Answer 3

true

Choice 4

I can only have one more baby.

Rationale 4

Future pregnancies are not limited to one.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Analyzing

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Evaluation

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO08_Q12

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:

Meta 4

admin

Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Learning Outcome 11:
Learning Outcome 12:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

LO07 - Explain the indications for cesarean birth, impact on the family unit,
preparation and teaching needs, and associated nursing care.

Question 139583
Id:

139583

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
After being in labor for several hours with no progress, the patient is diagnosed with cephalopelvic
disproportion (CPD) and must have a cesarean section. The patient is being prepared for a cesarean delivery in
the operating room. The doctor is present. The nurse knows that the last assessment the nurse should make just
prior to the patients being draped for surgery is:
Stimulus

Answer
Choice 1

Maternal temperature.

Rationale 1

Maternal temperature is monitored by anesthesia personnel.

Answer 1

false

Choice 2

Maternal urine output.

Rationale 2

Maternal urine output is not significant at this point.

Answer 2

false

Choice 3

Vaginal exam.

Rationale 3

Vaginal exam is unnecessary when cephalopelvic disproportion (CPD) is

present.

Answer 3

false

Choice 4

Fetal heart tones.

Rationale 4

Fetal heart tones are assessed just prior to the start of surgery because the
supine position can lead to fetal hypoxia.

Answer 4

true

Global Rationale

Meta 1
Cognitive Level:

Analyzing

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Assessment

Content Area:
Content Area
Sub:

Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Chapter 23_LO08_Q13

Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
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LO07 - Explain the indications for cesarean birth, impact on the family unit,
preparation and teaching needs, and associated nursing care.

Question 139584
Id:

139584

Type:

MCSA

Calculator
:

false

Question
Title:
Difficulty
Level:

Question Stem
The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant
indicates that additional information is needed?
Stimulus

Answer
Choice 1

Since the scar on my belly goes down from my navel, I am not a candidate
for a VBAC.

Rationale 1

Skin incision is not indicative of uterine incision. Only the uterine incision is
a factor in deciding if VBAC is advisable. Classical vertical incisions on the
uterus have a higher rate of rupture and should not be attempted.

Answer 1

true

Choice 2

My first baby was in a breech position, so this pregnancy I can try a VBAC
if the baby is head-down.

Rationale 2

Non-repeating conditions such as any non-vertex presentation might make

VBAC a viable option as long as this pregnancy is vertex.

Answer 2

false

Choice 3

Because my hospital is so small and in a rural area, they wont let me

attempt a VBAC.

Rationale 3

A repeat cesarean must be able to be performed immediately to safely

attempt a VBAC. Many small and rural hospitals do not have surgical and
anesthesia staff available at night, and on weekends and holidays, and
therefore do not allow patients to have a VBAC.

Answer 3

false

Choice 4

The rate of complications from VBAC is lower than the rate of

complications from a cesarean.

Rationale 4

The incidence of uterine rupture is 0.9%. Women who have a successful

VBAC have lower incidences of infection, less blood loss, fewer blood

transfusions, and shorter hospital stays.

Answer 4

false

Global Rationale

Meta 1
Cognitive Level:

Analyzing

Client Need:

Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated
Concepts:

Nursing Process: Evaluation

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Reference:
Source Id:

Chapter 23_LO09_Q14

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Standard 6:

LO08 - Examine the risks, guidelines, and nursing care of the woman
undergoing vaginal birth following cesarean birth.