NR-327 Maternal-Child Nursing - Set 4 - Part 2

Correct Answer: Shoulder dystocia behind the symphysis

The turtle sign is the hallmark of shoulder dystocia. The head retracts against the perineum because the anterior shoulder is impacted behind the pubic symphysis, and the trunk cannot advance. Option a is incorrect because a prolapsed cord announces itself before the head is born, with a sudden prolonged deceleration and a cord that is seen or felt in the vagina. Option b is incorrect because uterine rupture tears the myometrium during labor rather than obstructing the shoulders. Its picture is tearing pain, loss of station and shock, not a head that recoils. Option d is incorrect because embolism of amniotic fluid strikes the mother, producing abrupt dyspnea, hypoxia and collapse. Nothing about it explains a fetal head that will not advance past the perineum.

Correct Answer: It supports the lower segment against inversion

The postpartum uterus is heavy and hangs from lax ligaments, so downward pressure on the fundus alone can pull it inside out through the cervix. The anchoring hand blocks that catastrophic event. Option b is incorrect because fundal size is judged by the palpating hand at the top, counted in fingerbreadths from the umbilicus. Nothing about the suprapubic hand contributes to measuring width or height. Option c is incorrect because pressing above the pubic bone cannot drain urine, and a distended bladder must be relieved before palpation begins. The client voids first so the reading is trustworthy. Option d is incorrect because comfort comes from analgesia given ahead of the assessment, not from hand placement. Palpation and massage hurt regardless, which is why the nurse warns her and medicates when time allows.

Correct Answer: Assess her safety now and notify the provider

Any positive response to the self harm question demands immediate assessment no matter what the total shows. The nurse asks directly about intent, keeps her from being alone, and alerts the provider for evaluation. Option a is incorrect because filing the form and waiting four weeks ignores the one answer that overrides the total. A screening tool flags risk so it can be acted on the same day. Option b is incorrect because telling her the number looks fine contradicts what she just disclosed. Women can score under the threshold and still be in danger, which is precisely why that item is read separately. Option d is incorrect because repeating a questionnaire yields another number rather than a conversation. What is needed is a direct, calm interview about her thoughts, not a second pass through the same paper.

Correct Answer: The bleeding comes from a genital tract laceration

A well contracted midline fundus rules out atony, so bright red bleeding that keeps trickling points to torn tissue. Forceps raise laceration risk, and the provider must inspect and repair the site. Option a is incorrect because atony produces a soft uterus that is hard to locate and often rides above the umbilicus. This client's firm midline fundus is already compressing the placental bed effectively. Option c is incorrect because retained fragments usually declare themselves days later with lochia that stays rubra and a uterus larger than expected. Half an hour after birth is too early for that pattern. Option d is incorrect because coagulopathy shows itself as oozing from several places at once, including intravenous sites, gums, and any incision. Bleeding confined to the vagina does not fit that picture.

Correct Answer: Provide a stool softener and treat her pain

A softener plus real pain control addresses both causes at once. She is afraid to bear down, and sluggish bowel tone with lost fluid has hardened the stool, so nothing rectal is used after this repair. Option a is incorrect because a suppository must pass through the anal sphincter that was just sewn back together. Anything inserted rectally after a third or fourth degree repair risks disrupting the suture line. Option b is incorrect because enema tubing and the volume it delivers place direct pressure on a fresh rectal repair. The same rule bars rectal thermometers for this client until healing is complete. Option c is incorrect because holding back fluid hardens stool further and works against everything the nurse wants here. Six to eight glasses daily, fiber, and early walking are what restore a normal pattern.

Correct Answer: Water intoxication with dilutional hyponatremia

Oxytocin has an antidiuretic effect, so a prolonged high dose infusion retains free water. Headache, vomiting, confusion, falling sodium, and oliguria together mean the infusion is stopped and electrolytes are checked. Option b is incorrect because magnesium is not part of this client's regimen, and its picture is flushing, lethargy, absent reflexes, and slowed breathing. Calcium gluconate reverses that problem, not this one. Option c is incorrect because intrauterine infection shows up as fever, uterine tenderness, foul fluid, and fetal tachycardia. Confusion and a shrinking urine output do not belong to that pattern at all. Option d is incorrect because a tear in the wall declares itself through the fetal heart rate first, then tearing pain, loss of station, and signs of shock. None of those appear in this description.

Correct Answer: Newborn arm movement and maternal bleeding

Shoulder dystocia injures the brachial plexus, so the nurse checks arm movement, the Moro response and the clavicles. The mother's most common complication is hemorrhage, making uterine tone and blood loss equally urgent. Option a is incorrect because hip abduction screening for developmental dysplasia belongs to the routine newborn examination and follows breech birth, while calf tenderness points toward a clot forming days later. Option c is incorrect because measuring the head and taking a temperature are ordinary admission tasks. Neither one detects the nerve injury or the heavy bleeding that this difficult birth actually threatens. Option d is incorrect because sucking and maternal glucose sit far down the list right now. A newborn of a diabetic mother needs glucose checks, but the arm and the fundus come first.

Correct Answer: Postpartum blues, common and self limiting

Blues affect most new mothers, begin in the first days, peak around the fourth or fifth day, and clear by about day ten. Function stays intact, so reassurance and rest suffice. Option a is incorrect because depression brings persistent hopelessness, guilt, and difficulty caring for herself or the baby, lasting well beyond two weeks. Tearfulness on day four with preserved function does not meet that bar. Option b is incorrect because psychosis involves delusions, hallucinations, and a loss of contact with reality. A woman who describes her own mood swings accurately and tends her infant retains the insight psychosis destroys. Option c is incorrect because that label describes chronic, excessive worry present long before the birth. Nothing here suggests a longstanding pattern, and the timing points squarely at a normal postpartum adjustment.

Correct Answer: Retained placental fragments in the uterus

Lochia that returns to rubra beyond the first week, with clots and heavy flow, is the classic late hemorrhage picture. Fragments left behind keep the uterus from contracting down and need ultrasound and evacuation. Option b is incorrect because menses rarely return this early, especially in a breastfeeding woman, and a normal period does not deliver clots with flow heavier than usual. The timing and volume both argue against it. Option c is incorrect because heavy activity can briefly increase lochia, yet it does not turn discharge back to rubra or produce clots twelve days out. Attributing this to overdoing chores delays a needed evaluation. Option d is incorrect because serosa is pinkish brown and lighter, appearing near the fourth day and thinning further afterward. Bright red discharge with clots is a reversal of that sequence rather than part of it.

Correct Answer: Observe the client and provide symptom teaching

Preterm labor requires regular contractions plus documented cervical change. With an unchanged cervix on serial examinations, this client is observed, hydrated, and discharged with explicit teaching about which symptoms bring her back. Option a is incorrect because magnesium sulfate carries respiratory, reflex, and renal hold parameters that no one accepts for a cervix that has not changed. Tocolysis treats confirmed preterm labor, not contractions alone. Option b is incorrect because terbutaline is reserved for short term uterine relaxation in an acute event such as tachysystole. Admitting this client commits her to a drug whose risks outweigh any benefit here. Option d is incorrect because nothing in this picture points toward imminent delivery. The cervix is closed and unchanged, so preparing a birth room would alarm the client and divert the nurse from useful teaching.

Correct Answer: Assist the client to empty her bladder

A full bladder sits directly under the uterus and shoves it upward and laterally, blocking the myometrium from contracting down. Emptying it restores midline position and tone, so voiding comes before anything else. Option a is incorrect because a uterus above the umbilicus and off midline is never a normal finding at any hour. Charting it as routine would let the displacement and the bleeding risk continue unchecked. Option b is incorrect because heat over the abdomen does nothing to drain a distended bladder and can worsen swelling in nearby tissue. Warmth belongs to afterpain relief, not to correcting uterine displacement. Option c is incorrect because repositioning changes only the angle of palpation while the bladder stays full. Supine placement with flexed knees helps the nurse feel the fundus, yet it corrects nothing about the cause.

Correct Answer: Keep the hand in place until birth

Manual elevation is what keeps blood flowing through the compressed cord, so the hand stays put through transfer, prepping and draping until the newborn is delivered. Someone else performs every other task. Option b is incorrect because the prep is done around the nurse's arm rather than after it comes out. Releasing the presenting part returns the full weight of the fetus onto the cord. Option c is incorrect because anesthesia relieves the mother's pain and changes nothing about the trapped cord. Fetal oxygenation depends on the lift itself, which must continue while the surgeon opens the abdomen. Option d is incorrect because pressure from outside cannot reach a cord pinned between the fetal head and the bony pelvis. Only a hand inside the vagina can raise the presenting part off it.

Correct Answer: It speeds lung maturity by increasing surfactant production

Antenatal corticosteroids stimulate surfactant production and accelerate fetal lung maturity, which lowers rates of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and newborn death. Benefit peaks between forty eight hours and seven days. Option a is incorrect because relaxing uterine muscle is the job of the tocolytic she may also be receiving. Steroids do nothing to contractions, and labor often continues while the doses are given. Option c is incorrect because magnesium sulfate carries the neuroprotective indication, given when birth before thirty two weeks is expected to reduce cerebral palsy. Betamethasone targets the lungs, not the developing brain. Option d is incorrect because antibiotics cover infection risk, whether as group B streptococcus prophylaxis or as latency therapy after rupture. A steroid actually raises the white count transiently, which can confuse an infection workup.

Correct Answer: Piggybacking it to the main line on a pump

Oxytocin is always diluted, controlled by a pump, and piggybacked into the primary line at the port nearest the insertion site. That setup lets the nurse stop it instantly with almost no residual drug. Option a is incorrect because undiluted oxytocin pushed into a vein drops blood pressure sharply. The drug is titrated in milliunits per minute, a dose impossible to control by hand from a syringe. Option b is incorrect because a single line leaves no route for fluids once the drug is stopped. Part of the response to tachysystole is a bolus of isotonic solution, which needs a maintained primary line. Option d is incorrect because mixing the drug into the primary bag makes it impossible to stop separately, and gravity cannot deliver a precise rate. Both features defeat the safety design of this infusion.

Correct Answer: Perineal lacerations and neonatal intracranial bleeding

Rapid descent without gradual molding can bleed inside the newborn's skull, and the birth canal tears when it stretches too fast. Uterine atony with hemorrhage is the other maternal risk to expect. Option a is incorrect because a labor of under three hours is the opposite of a prolonged one. Low newborn glucose belongs with diabetic mothers and growth restricted infants rather than with speed. Option b is incorrect because a cervix that opened this fast never needed help softening. Macrosomia belongs to the slow obstructed labors, where the fetus is too large for the pelvis to allow passage. Option c is incorrect because previa is a placenta covering the cervix, diagnosed long before labor and a reason for cesarean. Newborn jaundice arises days later from bilirubin, not from a fast birth.

Correct Answer: Preparing for birth with broad spectrum intravenous antibiotics

Fever, uterine tenderness, foul fluid, and fetal tachycardia point to chorioamnionitis, and infection is a firm contraindication to tocolysis. Continuing this pregnancy is more dangerous than delivering, so birth plus antibiotics follows. Option a is incorrect because calcium channel blockade would prolong exposure of an infected uterus to bacteria. Nifedipine also drops maternal blood pressure, which further threatens perfusion to a fetus already showing tachycardia. Option c is incorrect because indomethacin belongs to short courses before thirty two weeks in the absence of infection. Here it would mask fever while the newborn faces a rising risk of sepsis. Option d is incorrect because magnesium sulfate is a weak tocolytic whose modern role is fetal neuroprotection. Delaying birth for a client with chorioamnionitis worsens outcomes for both of them rather than improving either.

Correct Answer: Rupture of the uterus through the scar

Tearing pain, contractions that suddenly cease, and a presenting part that has risen out of reach describe rupture of the scarred uterus. Bleeding is often concealed inside the abdomen rather than visible. Option a is incorrect because abruption keeps the uterus rigid, tender and contracting rather than silent. The presenting part also stays where it was, since the placenta separates without tearing the uterine wall. Option b is incorrect because weak ineffective contractions in the active phase define hypotonic dysfunction. That pattern slows progress gradually and produces mild discomfort, not a sudden tearing pain with a vanishing station. Option d is incorrect because embolic collapse begins in the mother's lungs and heart with dyspnea, hypoxia and hypotension. Abdominal pain with a retracting fetal head is not part of that syndrome.

Correct Answer: A pad saturated within fifteen minutes

Soaking an entire pad in a quarter hour, or bleeding in a steady stream, signals hemorrhage. Weighing the soiled items gives a truer figure, since visual guesses understate large losses badly. Option b is incorrect because dark red flow with occasional small clots is the expected pattern in the early hours. Clots the size of a plum or larger would be the worrying variation. Option c is incorrect because a moderate stain describes an amount well within normal limits for this stage. Describing saturation by area rather than by time also hides how fast the blood is arriving. Option d is incorrect because dampening a single pad over an hour represents light flow and reassures rather than alarms. That rate falls far below the threshold clinicians use to call bleeding excessive.

Correct Answer: Obtain the operative report from the prior birth

The skin incision says nothing about the uterine one, and only a low transverse uterine scar makes labor safe. The operative report settles it, because a classical incision rules a trial of labor out. Option a is incorrect because a bikini scar on the belly can sit above a vertical cut in the uterus. Promising her a safe labor on that assumption risks a rupture during contractions. Option b is incorrect because the decision belongs to the client after an honest discussion of both routes. Booking surgery without that conversation removes her choice and ignores information that is easy to retrieve. Option d is incorrect because the length and angle of a healed skin scar reveal nothing about the closure underneath. Documenting its appearance adds a detail to the chart but answers no clinical question.

Correct Answer: A transcervical balloon catheter placed by the provider

An unfavorable cervix needs ripening before oxytocin. A mechanical balloon works by pressure and local prostaglandin release, carries no tachysystole risk, and is the preferred choice for a client with a uterine scar. Option a is incorrect because misoprostol cannot be retrieved once it is placed and is contraindicated with any uterine scar. Rupture risk is the reason that door closes for this client. Option c is incorrect because inducing an unfavorable cervix produces long inductions and more cesareans. A Bishop score this low calls for softening first, and high dose protocols are not used with a scarred uterus. Option d is incorrect because rupturing membranes demands an engaged cephalic presenting part. Breaking the bag under a floating head invites the cord to slip past it, which is the complication everyone is trying to avoid.