ATI Quiz #3

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep four side rails up while the client is in bed. B. Check the cervix prior to analgesic administration. C. Monitor the fetal heart rate (FHR) every hour. D. Insert an indwelling urinary catheter.

b

A nurse in the L&D unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal HR behind 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? a. Place the client in the lateral position. b. Increase the rate of maintenance IV infusion. c. Elevate the client's legs. d. Administer oxygen using a nonrebreather mask.

a

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? a. Uteroplacental insufficiency b. Maternal bradycardia c. Umbilical cord compression d. Fetal head compression

a

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? a. contractions lasting longer than 90 seconds b. contractions occurring every 3 to 5 min c. contractions are strong in intensity d. client reports feeling contractions in lower back

a

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

a

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? a. The presenting part is 1 cm above the ischial spines. b. The presenting part is 1 cm below the ischial spines. c. The cervix is 1 cm dilated. d. The cervix is effaced 1 cm.

a

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? a. variable decelerations are due to umbilical cord compression b. variable decelerations are caused by uteroplacental insufficiency c. variable decelerations are a result of the administration of IV narcotic analgesics d. variable decelerations are related to fetal head compression

a

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? a. Expulsion of a blood-tinged mucous plug b. Continuous contraction lasting 2 min c. Pressure on the perineum causing the client to bear down d. Expulsion of clear fluid from the vagina

b

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? a. Rupture of the membranes b. Changes in the cervix c. Station of the presenting part d. Pattern of contractions

b

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? a. Monitor the client's temperature. b. Assess the fetal heart rate. c. Assess the odor of the amniotic fluid. d. Provide clean, dry underpads.

b

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? a. The client reports weakness of the lower extremities. b. Blood pressure 80/56 mm Hg c. Temperature 38.2°C (100.8°F) d. The client reports perfuse itching.

b

A nurse is the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured 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? a. "You should go ahead and push to assist the delivery." b. "You should try to pant as the delivery proceeds." c. "You should try to perform slow-paced breathing." d. "You should take a deep, cleansing breath and breathe naturally."

b

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a durtiong of 1min and a frequency of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54mmHg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Have the client void

b

a nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. which of the following is the priority action for the nurse to take? a. cut the umbilical cord b. apply perineal pressure to the emerging fetal head c. prevent the perineum from tearing d. promote delivery of the placenta

b

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? a. Two veins and one artery b. One artery and one vein c. Two arteries and one vein d. Two arteries and two veins

c

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 vaginal examination. Which of the following actions should the nurse take? a. Apply fundal pressure. b. Observe for the presence of a nuchal cord. c. Observe for crowning. d. Prepare to administer oxytocin.

c

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? A. Vertex B. Shoulder C. Breech D. Mentum

c

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. contractions that last for 60 seconds each with a 4-min rest between contractions b. a contraction that lasts 4 min followed by a period of relaxation c. contractions that last for 60 seconds each with a 3-min rest between contractions d. contractions that last 45 seconds each with a 3-min rest between contractions

c

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? A. The fetal head is in the left occiput posterior position. B. The largest fetal diameter has passed through the pelvic outlet. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

d

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? a. Maintain the client in the lithotomy position. b. Perform vaginal examinations frequently. c. Remind the client to bear down with each contraction. d. Encourage the client to empty her bladder every 2 hr.

d

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. 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? a. Cephalic b. Transverse c. Posterior d. Frank breech

d

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

d

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

d

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? a. Palpate the client's uterus. b. Administer oxygen to the client. c. Increase the client's IV fluid infusion rate. d. Turn the client onto her side.

d

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 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? a. Elevate the client's legs. b. Monitor vital signs every 5 min. c. Notify the provider. d. Place the client in a lateral position

d

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

d

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? A. Have the client stand at the bedside with her arms at her side. B. Administer a 500mL bolus of 5% dextrose in water prior to induction. C. Inform the client the anesthetic effect will last for approximately 6hr. D. Obtain a 30min electronic fetal monitoring (EFM) strip prior to induction.

d

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? a. Fetal attitude is in general flexion. b. Fetal lie is longitudinal. c. Maternal pelvis is gynecoid. d. Fetal position is persistent occiput posterior.

d

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, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over.Which of the following actions should the nurse take? a. Slow the client's rate of breathing b. Increase the rate of infusion of the IV oxytocin c. Decrease the rate of infusion of the maintenance IV solution d. Discontinue the infusion of the IV oxytocin

d

a nurse is caring for a client who is in active labor when the client's membranes rupture. the fetal monitor tracing shows late decelerations. which of the following actions should the nurse take first? a. palpate the client's uterus b. administer oxygen to the client c. increase the client's IV fluid infusion rated. d. turn the client onto her side

d