ATI NSG 4525 Intrapartum

​A nurse is caring for a client in the first stage of labor who is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? -Administer oxygen via nasal cannula. -Assist the client to breathe into a paper bag. -Have the client tuck her chin to her chest. -Instruct the client to increase her respiratory rate to more than 42 breaths per min.

Assist the client to breathe into a paper bag. - This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? -Expulsion of a blood-tinged mucous plug -Continuous contraction lasting 2 min -Pressure on the perineum causing the client to bear down -Expulsion of clear fluid from the vagina

Continuous contraction lasting 2 min - A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has reptured membranes, and the nurse observes the newborn's head is crowning. the client tells the nurse she wants to push. Which of the following statements should the nurse make? -"You should go ahead and push to assist the delivery." -"You should try to pant as the delivery proceeds." -"You should try to perform slow-paced breathing." -"You should take a deep, cleansing breath and breathe naturally."

"You should try to pant as the delivery proceeds." - Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head.

A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority action by the nurse following the procedure? -Observe color and consistency of fluid. -Assess the fetal heart rate pattern. -Assess the client's temperature. -Evaluate client for the presence of chills and increased uterine tenderness using palpation.

Assess the fetal heart rate pattern.- Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? -Monitor the client's temperature. -Assess the fetal heart rate. -Assess the odor of the amniotic fluid. -Provide clean, dry underpads.

Assess the fetal heart rate.- The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? -The fetal head is in the left occiput posterior position. -The largest fetal diameter has passed through the pelvic outlet. -The posterior fontanel is palpable. -The lowermost portion of the fetus is at the level of the ischial spines.

The lowermost portion of the fetus is at the level of the ischial spines. - The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.

A nurse is caring for a client who is in labor and had an external fetal monitor. The nurse observed late deceleration on the monitor strip and interprets them as indicating which of the following? -Uteroplacental insufficiency -Maternal bradycardia -Umbilical cord compression -Fetal head compression

Uteroplacental insufficiency - The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.

A nurse is observing the electronic fetal heart rate monitor for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect cord compression when she observes which of the following patterns? -Early decelerations -Accelerations -Late decelerations -Variable decelerations

Variable decelerations - Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus.

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? -Variable decelerations are due to umbilical cord compression. -Variable decelerations are caused by uteroplacental insufficiency. -Variable decelerations are a result of the administration of IV narcotic analgesics. -Variable decelerations are related to fetal head compression.

Variable decelerations are due to umbilical cord compression. - Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, lasting 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with a uniform deceleration beginning at the peak of the contraction and a return to baseline after the contractions is over. Which of the following actions should the nurse take?--Decrease the rate of infusion of the maintenance IV solution -Discontinue the infusion of the IV oxytocin -Increase the rate of infusion of the IV oxytocin -Slow the client's rate of breathing

Discontinue the infusion of the IV oxytocin. - Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? -Maintain the client in the lithotomy position. -Perform vaginal examinations frequently. -Remind the client to bear down with each contraction. -Encourage the client to empty her bladder every 2 hr.

Encourage the client to empty her bladder every 2 hr. - A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

A nurse is caring for a client who is in active labor at 39 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? -Cephalic -Transverse -Posterior -Frank breech

Frank breech - With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? -Cover the cord with a sterile, moist saline dressing. -Prepare the client for an immediate birth. -Place the client in knee-chest position. -Insert a gloved hand into the vagina to relieve pressure on the cord.

Insert a gloved hand into the vagina to relieve pressure on the cord. - This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vagina exam. Which I the following actions should the nurse take? -Apply fundal pressure. -Observe for the presence of a nuchal cord. -Observe for crowning. -Prepare to administer oxytocin.

Observe for crowning.- In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mmHg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? -Elevate the client's legs. -Monitor vital signs every 5 min. -Notify the provider. -Place the client in a lateral position.

Place the client in a lateral position - Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. the nurse observes the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? -Place the client in the lateral position. -Increase the rate of maintenance IV infusion. -Elevate the client's legs. -Administer oxygen using a nonrebreather mask.

Place the client in the lateral position. - This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse perform? -Prepare for a cesarean birth. -Assist the client to an upright position. -Prepare for an immediate vaginal delivery. -Assist the client to turn onto her side.

Assist the client to turn onto her side. - Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.

A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take? -Infuse a bolus of IV fluid. -Administer hydralazine 25 mg IV. -Prepare the client for immediate delivery. -Administer betamethasone 12 mg IM.

Administer betamethasone 12 mg IM. - Betamethasone is classified as a corticosteroid medication. Corticosteroids are often administered to the mother to assist in fetal lung maturity. These are usually administered by IM injection of 12 mg for the first two doses. The subsequent dosing should be 6 mg by IM every 12 hr x 4 doses.

A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which of the following actions should the nurse take first? -Apply a fetal scalp electrode. -Increase the rate of the IV infusion. -Administer oxygen at 10 L/min via a nonrebreather mask. -Change the client's position.

Change the client's position.- The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? -Rupture of the membranes -Changes in the cervix -Station of the presenting part -Pattern of contractions

Changes in the cervix - Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which information should the nurse include? -"This medication will help prevent nausea and vomiting." -"Your contractions will become stronger and more frequent." -"I will remove the electronic fetal monitor once contractions are regular." -"You can push the button on the control device to administer more medication."

"Your contractions will become stronger and more frequent." - Oxytocin is diluted with sodium chloride and administered IV via an infusion pump device to induce or strengthen uterine contractions during labor. The client who is receiving an oxytocin drip is closely monitored to promote a safe delivery and prevent maternal and/or fetal complications. The desired concentration of oxytocin medication is determined by the desired labor contraction pattern that should increase in frequency, duration, and intensity. The nurse closely monitors risks of continuous IV infusion of oxytocin to determine when to discontinue the medication. Risks include fetal distress (fetal bradycardia) caused by hyper-stimulation of the uterus compromising blood flow to the fetus. Uterine contractions lasting longer than 90 seconds should prompt the nurse to discontinue the medication.

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? -Cervical dilation -Report of pain above the umbilicus -Brownish vaginal discharge -Amniotic fluid in the vaginal vault

Cervical dilation - Cervical dilation and effacement are indications of true labor.