Birth

The nurse is assessing fetal presentation in a multiparous client. The illustration indicates which type of presentation? 1. frank breech 2. complete breech 3. footling breech 4. vertex

1 (breech presentations account for approx. 5% of all births. and the most common is frank breech. In frank breech there is flexion of the fetal thighs and extension of the knees. The feet rest at the side of the fetal head. In completed breech, there is flexion of the fetal thighs and knees; the fetus appears to be squatting. Footling breech occurs when there is an extension of the fetal knees and one or both feet protrude thru the cervix. Vertex presentation occurs in 95% of births with the head engaged in the pelvis)

On exam of a full term primipara a labor nurse notes; active labor, ROA, 7cm dilated, and +3 station. Which of the following should the nurse report to the HCP> 1 Descent is progressing well 2,, Fetal head is not yet engaged 3. Vaginal delivery is imminent 4. external rotation is complete

1 (descent is progressing well The presenting part is 3 cm below the ischial spines. The fetal head is well past engagement, engagement is defined as 0 station. The woman is a primipara at only 7cm, delivery is likely hours away. External rotation does not occur until after delivery of fetal head.)

The nurse is educating the client regarding the moves the fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. descent 2. expulsion 3. extension 4. external rotation 5. internal rotation

1 5 3 4 2

A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which signs and symptoms? select all that apply 1. bleeding that is concealed or apparent 2. abdominal rigidity 3. painful abdomen 4. painless bleeding 5. large placenta 6. bleeding that stops spontaneously

1,2,3 (with abruptio placentae, bleeding may occur vaginally, may be obstructed by the fetal head, or it may be hidden behind a portion of the placenta. Abdominal rigidity occurs, particularly with a concealed hemorrhage because the girth and fundal height increase. Abdominal pain is one of the classic symptoms of abruption. The pain may be intermittent, as in labor contractions, or continuous. The placenta with abruption is not larger than a normal placenta, and the bleeding does not end spontaneously.)

What is this position? 1. ROP 2. LOP 3. ROA 4. LOA

2 (Left occiput posterior)

The nurse is managing care of a primigravida at full term who is in active labor. What should be included in developing the plan of care for this client? 1. O2 sat monitoring every 30 minutes 2. supine positioning on back, if it is comfortable 3. anesthesia/pain level assessment ever 30 minutes 4. vaginal bleeding, rupture of membranes assessment every shift

3 (the nurse should monitor anesthesia and pain levels every 30 mins during active labor to ascertain that this client is comfortable during labor and particularly during active labor when pain accelerates. When in active labor O2 sat is not monitored unless there is a specific need, such as heart disease. The client should not be on her back but wedged to the right or left sideto take the pressure off the vena cava. When lying on the back the fetus compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30 min to 1 hr.)

Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. the client has severe back pain during this phase of labor. The nurse explains that the clients severe back pain is most likely caused by the fetal occiput being in which position? 1. breech 2. transverse 3. posterior 4. anterior

3 (when a client has severe back pain during labor the fetus is most likely in an occipitoposterior position. This means that the fetal head presses against the clients sacrum ,causing marked discomfort during contractions. These sensations may be so intense that the client requests medication for relief of the back pain rather than the contractions. Breech presentation and transverse lie are usually known prior to 8 cm dilation and a cesarean section is performed. Fetal occiput anterior position does not increase the pain felt during labor.)

A 30 year old G3 T2 P0 A0 L2 is being monitored internally, She is being induced with IV oxytocin because she is post-term. The nurse notes the pattern below. the client is wedged to her side while lying in bed and is approx 6 cm dilated and 100% effaced. The nurse should first: 1. continue to observe the fetal monitor 2. anticipate rupture of the membranes 3. prepare for fetal oximetry 4. DC the oxytocin infusion

4 (The fetal monitor strip shows late decelerations. The first intervention would be to turn off the oxytocin because the med is causing the contractions. The stress caused by the contractions demonstrates that the fetus is not being perfused during the entire contraction (as shown by the late decels) There is no time to continue to observe in this situation; intervention is a priority. The client is attached to an internal fetal monitor, which would only be possible if her membranes had been already ruptured. If the fetus continues to experience stress, fetal oximetry may be initiated)

Upon exam the nurse notes that a woman is 10 cm dilated, 100% effaced and -3 station. Which of the following actions should the nurse perform during the next contraction? 1. encourage the woman to push 2. provide firm fundal pressure 3. move the client to squat 4. monitor for signs of rectal pressure

4 (monitoring for signs of rectal pressure is appropriate. Pushing is better to wait until the woman exhibits signs of rectal pressure, pushing a baby not yet engaged may result in overly fatigued woman or more significantly a prolapsed cord)

The nurse is performing a vaginal exam on a client in labor. The client is found to be 5 cm dilated 90% effaced and station -2. Which of the following has the nurse palpated? 1. thin cervix 2. bulging fetal membranes 3. head at pelvic inlet 4. closed cervix

1

The nurse explains to a newly admitted client in active labor that according to the gate control theory of pain a closed gate means that the client should exxperience what type of pain? 1. no pain 2. sharp pain 3. light pain 4. moderate pain

1 (According to gate control theory of pain a closed gate means that the client should feel no pain. The gate control theory of pain refers to the gate control mechanisms in the substantia gelatinosa of the spinal cord so the impulse is never perceived at the brain level as pain)

The childbirth education nurse is evaluating the learning of four young women, 38 to 40 weeks gestation regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements; select all that apply 1. If I feel a pain in my back and lower abdomen every 5 minutes 2. When I feel a gush of clear fluid from my vagina 3. When I go to the bathroom and see the mucous plug on the toilet tissue 4. If I ever notice a greenish discharge from my vagina 5. When I have felt cramping in my abdomen for 4 hrs or more

1,2,4 (1. True labor contractions often begin in the back and when the freq of the contractions is q 5 min or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of the membranes is a reason to go to the hospital to be assessed. 4. greenish liquid is likely meconium stained fluid the client needs to be assessed.)

A nurse is caring for a laboring woman who is in transition. Which of the following S/S would indicate that the woman is progressing into the second stage of labor? select all that apply 1. bulging perineum 2. increased bloody show 3. spontaneous rupture of membranes 4. uncontrollable urge to push 5 inability to breathe thru contractions

1,2,4 (As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. ***amniotic sac can rupture at any time not an indication of 2nd stage)

The nurse has just received report on a labor client. A G3 T1 P0 A1 L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shift will address what factors? select all that apply 1. This client will give birth before the change of shift in 12 hours 2. Pushing the baby out should take 30 mins or less 3. contractions will remain irregular until transition 4. transition will be shorter for this multiparous client 5. This client will withdraw into herself during transition

1,2,4,5 (a multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 mins or less and many multiparous clientst go immed from 10 cm to birth. Contractions become regular and increase in frequency intensity and duration as labor progresses for both primi and multiparous clients. transition will be shorter for a multi parous client than it will for a primiparous, as the entire labor process takes less time for someone with a previous delivery. This client will withdraw into herself during transition, and this is a common characteristic for those in the transition phase)

A primigravid client at 38 weeks is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, I need to push!, What should the nurse do next? 1. use the McDonald procedure to widen the pelvic opening 2. increase the rate of O2 and IV fluids 3. instruct the client to use a pant-blow pattern of breathing 4. Tell the client to push only when absoluteley necessary.

3 (pushing during the first stage of labor when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more difficult, The client should be encouraged to use a pant-blow pattern of breathing to help overcome the urge to push. The client should not push even if she feels the urge to do so because this may result in cervical edema at 7 cm dilation)

What interval should the nurse use when assessing the frequency of contractions in a multiparous client in active labor admitted to the birthing area? 1. acme of one contraction to the beginning of the next contraction 2. beginning of one contraction to the end of the next contraction 3. end of one contraction to the end of the next contraction 4. beginning of one contraction to the beginning of the next contraction

4 (To assess the frequency of the clients contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction, The acme identifies the peak of a contraction)

What is this position? 1. LSA 2. RSP 3. LSP 4. RSP

1 (left sacral anterior. The position is defined as the direction in which the fetal presenting part is pointed in relation to the maternal pelvis, that is the mothers left/right and the anterior/posterior. In other words determine toward which part of the mother the presenting part of the fetus is pointing. In this question fo rexample, the sacrum of the fetus is pointing toward the left anterior of the mother)

A nurse concludes that a woman is in the latent stage of labor. Which of the following S/S would lead a nurse to that conclusion? 1. the woman talks and laughs during contractions 2. the woman complains about severe back labor 3. the woman performs effleurage during a contraction 4. the woman asks to go to the bathroom to defecate

1 (talking and laughing are characteristic of the latent phase)

A woman who is in active labor is told by her obstetrician your baby is in the flexed attitude. when she asks the nurse what that means, what should the nurse say? 1. the baby is breech position 2. the baby is in the horizontal lie 3. the babys presenting part is engaged 4. the babys chin is resting on its chest

4 (when the baby is in the flexed attitude with the chin on chest the diameter of the fetal head entering the pelvis avg 9.5 cm but if it was extended attitude the fetal head entering the pelvis can be as large as 13.5 cm. Flexed is best for delivery)

What is this position? 1. ROP 2. LOP 3. ROA 4. LOA

3 (Right occiput anterior)

A client is induced with oxytocin. The FHR is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take? 1. Turn the client to her left side 2. admin O2 via face mask at 10-12L/min 3. Notify the HCP of the situation 4. Document fetal well being

4 (accels that are episodic and occur during fetal movement demonstrate fetal well being. Turning the client to the left side, applying O2 and notifying the HCP are interventions used for late and variable decels indicating the fetus is not tolerating induction process well)

The nurse while shopping in a local dept store hears a multiparous woman say loudly "I think my baby is coming". After asking someone to call 911, the nurse assists the client to give birth to a term meonate. While waiting for the ambulance the nurse suggests that the mother initiate breast feeding primarily for what reason? 1. to begin the parental infant bonding process 2. to prevent neonatal hypothermia 3. to provide glucose to the neonate 4. to contract the mothers uterus

4 (after emerg. birth, the nurse suggests the mother begin breast feeding to contract the uterus. Breast feeding stimulates oxytocin. In multiparous clients uterine atony is a potential complication because of the stretching of the uterine fibers following subsequent preg. Although breast feeding does help begin the parental infant bond it is not the primary reason. Prevention of neonatal hypothermia is accomplished by placing blankets on the neonate and mother. Although colostrum in breast milk provides the neonate nutrients and immunoglobulins, the primary reason for breast feeding is to stimulate the natural production of oxytocin to contract the uterus.)

While evaluating the fetal heart monitor tracing on a client in labor the nurse notes there are fetal heart decels present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decels and labor contractions 2. the maternal BP 3. the gestational age of the fetus 4. the placement of the fetal heart electrode in relation to the fetal position

1 (Early decels mirror contractions, late decels develop at the peak of contractions and return to baseline well after contractions are over, and variable decels can occur at anytime and are often unrelated to contractions)

The nurse is performing a vag exam on a client in labor. The nurse finds the fetal presenting part 1 cm above the ischial spines. The nurse should chart the station as 1. -1 station 2. +1 station 3. engaged 4. floating

1 (If presenting part is above the ischial spines 1cm, the station is -1. If the presenting part is 1 cm below the ischial spines, the station is +1. Engaged and floating are not descriptive of station)

A multigravid client who is 10 cm dilated is admitted to the labor and birth unit in addition to supporting the client, priority nursing care includes: 1. turning on the infant warmer 2. increasing IV fluids 3. determining the clients preferences for pain control 4. providing client education regarding care of the newborn

1 (Nursing care for this client includes providing support, preparing for birth, assessing for potential complications, and providing care for the newborn. Turning on the warmer is the best choice for providing for the care of the newborn. O2 and IV fluids may be indicated if variable or late deceleration are noted on the FH monitor, but decelerations are not indicated in the question. It is likely too late for pharm pain relief for a multigravid client. Education regarding care of the newborn is not appropriate at this time)

A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occipitoposterior (LOP) position has severe back pain. What intervention is most indicated? 1. provide firm pressure to the clients sacral area 2. prepare the client for a cesarean birth 3. prepare the client for a precipitate birth 4. Maintain the client in a left side lying position

1 (The client who has back pain during labor experiences marked discomfort because the fetus is in an LOP position. This pain is much greater when the fetus is in the anterior position because the fetal head impinges on the sacreum in the course of rotating to the anterior position. Application of a firm pressure to the sacral area can help alleviate the pain. Problems of severe back pain during labor typically do not require a cesearn. The HCP may elect to do an episiotomy, but it is not necessarily required. It is unlikely that a primigravid client with a fetus in LOP position will have a precipitous birth, rather llabor is usually prolonged. A hands and knees position or a right side lying position my help rotate the fetal head and thus alleviate some of the back pain)

The nurse is managing a pregnant clients second stage of labor. The nurse should intervene when observing which action? 1. closed glottis pushing 2. open glottis pushing 3. rest and descent 4. squatting while pushing

1 (closed glottis pushing or when a woman is told to hold her breath when she pushes typically while the nurse typically counts to 10, creates the valsalva maneuver and is associated with decreased perfusion. Open glottis pushing, on the other hand encourages women to listen to their own body cues for when to breathe and when to bear down. "rest and descent" and squatting have positive influences on the 2nd stage of labor)

The nurse begins her shift on the OB unit. There are several new admissions. The client with which condition would be a candidate for induction? 1. preeclampsia 2. active herpes 3. face presentation 4, fetus with late decelerations

1 (The client with preeclampsia would be a candidate for the induction process because ending the pregnancy is the only way to cure preeclampsia. A client with active herpes would be a candidate for a cesarean section to prevent the fetus from contracting the virus. The woman with a face presentation will not be able to give birth vaginally due to the extended position of the neck. The client whos fetus exhibits late decels indicate the fetus does not have enough placental reserves to remain oxygenated during the entire contraction, and may require c section.)

The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior LOA 2. Left sacral posterior LSP 3. Right mentum anterior RMA 4. Righ sacral posterior RSP

1 (The fetal back is felt on the mothers left side. The small parts are felt on her right side. The buttocks are felt in the fundal region. and the head is felt above her symphysis)

A 24 year old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin IV after delivery of the placenta. Which sign would indicate to the nurse that the placenta is about to be delivered? 1. The cord lengthens outside the vagina 2. There is decreased vaginal bleeding 3. The uterus cannot be palpated 4. The uterus changes to discoid shape

1 (The most reliable sign that the placenta etached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes more firm and changes in shape from discoid to globular. This process takes about 5 minutes if the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage)

For the past 8 hrs a 20 year old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor the nurse should observe the client for: 1. exhaustion 2. chills and fever 3. fluid overload 4. meconium status

1 (The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client is having prolonged labor, the nurse should monitor the client for signs of exhaustion as well as dehydration. Hypotonic contractions which are painful but ineffective may be occuring. Oxytocin augmentation maybe necessary. Chills and fever are manifestations of an infection and are not associated with a prolonged latent phase of labor. Fluid overload can occur from rapid infusion of IV fluids administered if the client is experiencing hemorrhage or shock. It is not associated with prolonged latent phase. The clients membranes are intact so it would be difficult to assess meconium staining of the fluid. Meconium stained fluids is associated with fetal distress, and this fetus appears to be in a healthy state as evidenced by a FHR wnl and good variability)

A primigravid client in active labor has had no anesthesia. The clients cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change form slow chest breathing to which breathing technique? 1. rapid shallow chest breathing 2. deep chest breathing 3. rapid pant blow breathing 4. slow abdominal breathing

1 (The psycho-prophylaxis method suggests using slow chest breathing until it becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at the sternum) during the peak of a contraction. The rate is 50-70 breathes per minute. Deep chest breathing is appropriate for the early phase of labor in which the client exhibits less frequent contractions When transitioning nears, a rapid pant blow pattern of breathing is used. Slow abdominal breathing is very difficult for clients in labor)

To determine whether the client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal exam. During the exam the nurse should palpate which cranial sutures? 1. sagittal 2. lambdoidal 3. coronal 4. frontal

1 (The sagittal suture is most readily felt during a vaginal exam. When the fetus is in the LOA position, the occiput faces the mothers left. the lambdoid suture is on the side of the skull. The coronal suture is horizontal suture across the front portion of the fetal skull that forms the anterior fontanelle. It may be felt with a brow presentation. The frontal suture may be felt with a brow or face presentation.)

What is this position? 1. ROP 2. LOP 3. LOA 4. ROA

1 (This is a picture of a fetus in the right occiput posterior position.)

A 31 year old multigravid client at 39 weeks gestation admitted to the hospital in active labor is recieving IV LR solution and a continuous epidural anesthetic. During the first hour after administration fo the anesthetic, the nurse should monitor the client for 1. hypotension 2. diaphoresis 3. headache 4. tremors

1 (When a client receives epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distension, prolonged second stage of labor, N/V, pruritus and delayed respiratory depression for up to 24 hours after admin. Diaphoresis and tremors are not usually associated with the admin of epidural anesthesia. Headaches, a common adverse effect of many drugs also is not associated with admin of epidural anesthesia.)

Which technique to promote active relaxation would the nurse include in the teaching plan for a 16 year old primigravid client in early labor? 1. relaxing uninvolved body muscles during uterine contractions 2. practicing being in a deep meditative sleep like state 3. focusing on an object in the room during the contractions 4. breathing rapidly and deeply between contractions

1 (birth educators use various techniques and methods to prepare parents for labor and birth. Active relaxation involves relaxing uninvolved muscle groups while contracting a specific group and using chest breathing techniques to lift the diaphragm off the contracting uterus. )

A primigravid client is admitted as an outpatient for an external cephalic version. Which factor would be a contraindication for the procedure? 1. multiple gestation 2. breech presentation 3. RH-negative blood type 4. history of gestational diabetes

1 (external cephalic version is the turning of the fetus from a breech presentation to the vertex position to prevent the need for a cesearean birth. Gentle pressure is used to rotate the fetus to a forward direction to a cephalic lie. Contraindications to the procedure include multiple gestation because of the potential for fetal injury or uterine injury, sever oligohydramnios, contraindications to a vaginal birth (cephalopelvic disproportion) and unexplained thrid trimester bleeding. If the the mother has RH neg blood type, the procedure can be performed and RH immunoglobulin should be administered in case minimal bleeding occurs. A history of gestational diabetes is not a contraindication unless the fetus is large for gestational age and the client has cephalopelvic disproportion.)

Before placing the fetal monitoring device on a primigravid clients fundus, the nurse performs Leopolds maneuvers. The nurse explains that third maneuver is done for which reason? 1. to determine whether the fetal presenting part is engaged 2. to locate the fetal cephalic prominence 3. to distinguish between a breech and a cephalic presentation 4. to locate the position of the fetal arms and legs

1 (leopolds maneuvers are performed to determine the presentation and position of the fetus. The third maneuver determines whether the fetal presenting part is engaged in the maternal pelvis. the first maneuver distinguishes between a breech and ccephalic presentation through palpatation of the top of the fundus. The second maneuver locates the fetal back for optimal FHR monitoring. The fourth maneuver is done to locate the fetal cephalic prominence if the fetus is in a cephalic position)

A client enters the L&D suite stating she thinks she is in labor. Which info about the woman should the nurse note from the womans prenatal record before proceeding to the physical assessment? 1. weight gain 2. ethnicity and religion 3. age 4. type of insurance 5. gravidity and parity

1,2,3,5

The HCP has performed an amniotomy on a laboring client. Which details must be included in the documentation of this procedure? select all that apply 1. time of rupture 2. color and clarity of fluid 3. FHR and pattern before and after procedure 4. size of amnio hook used during the procedure 5. odor and amt of fluid

1,2,3,5 (The time of rupture, color, odor, amount and clarity of amniotic fluid, FHR before and after are all info that must be documuented on the clients record. There is only one size amnio hook)

A nurse is preparing a change of shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply 1. interpretation of the fetal monitor strip 2. analgesia or anesthesia being used 3. previous methods of birth control 4. support persons with the client 5. prior birth history

1,2,4,5 (Knowledge of how the fetus is tolerating contractions as well as the freq, intensity, and duration of contractions, as indicated on the fetal monitor strip are extremely important. The type of analgesia or anesthesia being used, the clients response, and her pain rating should be included as well. The amount of vag bleeding indicates whether this labor is in the normal range. The support persons with the client are an integral part of the labor process and greatly influence how she manages labor emotionally and commonly physically. A complete change of shift report would include the clients name, age, gravida and parity, current and prior illnesses that may influence this hospitalization. prior labor and birth history if applicable, last vag exam time and findings, vag bleeding, support persons with the client, current IVs and other meds being used and pertinent lab test results. Previous use of birth control is not important at this time)

The HCP has informed the labor nurse that he believes the uterus has inverted in a primparous client who has just given birth. Which findings would help to confirm this diagnosis. select all that apply 1. hypotension 2. gush of blood from the vagina 3. intense severe tearing type of abdominal pain 4. uterus is hard and in a constant state of contraction 5. inability to palpate the uterus 6. diaphoresis

1,2,5,6 (uterine inversion is indicated by a sudden gush of blood from the vagina leading to decreased blood pressure, and an inability to palpate the uterus since it may be in or protruding from the vagina, and any signs of blood loss such as diaphoresisi, paleness, or dizziness could be observed at this time. Intense pain and a hard contracting uterus are not associated with uterine inversion)

The nurse is discussing pain relief methods for a pregnant first-time mom. The discussion should include which labor support methods? select all that apply 1. effleurage 2. positive reinforcement 3. guided imagery 4. pattern paced breathing 5. self containment theory 6. progressive relaxation

1,3,4,6 (effleurage is a method of light massage that can provide pain relief. Guided imagery is a relaxation technique used in birth preparation, as is pattern paced breathing. Positive reinforcement is not a labor support method, nor is self containment theory)

The nurse assesses a primiparous client with the ruptured membraines in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? select all that apply; 1. administer O2 via mask to the client 2. questioning the client about the effectiveness of pain relief 3. placing the client on her side 4. readjusting the monitor to a more comfortable position 5. applying the internal fetal monitor

1,3,5 (Decelerations alert the nurse that the fetus is experiencing decreased blood flow from the placenta. Administering O2 will increase tissue perfusion. Placing the mother on her side will increase placental perfusion and decrease cord compression. Using an internal fetal monitor would help in identifying the possible underlying cause of the decelerations, such as metabolic acidosis. Assessing for pain relief and readjusting the monitor would have no effect on correcting the late decelerations.)

A nurse and a UAP are caring for clients in a labor and birth unit. Which task should the registered nurse assign to the UAP? 1. perform a fundal check on a 2 day postpartum client 2. remove a fetal monitor and assist a client to the bathroom 3. give ibuprofen 800 mg by mouth to a newly postpartum client 4. teach a new mother how to bottle feed her infant

2

A nurse is assessing VS in a client in labor at the peak of contraction Which of the following findings would the nurse expect to see? 1. decreased pulse rate 2. hypertension 3, hyperthermia 4. decreased rr

2

A woman is in the transition stage of labor. Which of the following comments should the nurse expect to hear? 1. I am so excited to be in labor 2. I cant stand this pain any longer 3. I need ice chips I am so hot 4. I have to push this baby out right now

2

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must the nurse perform at this time? 1. Place the client in the lateral recumbent position 2, carefully analyze the baseline data on monitor tracing 3, admin O2 to mom via face mask 4. ask the mother to indicate when she feels fetal movement

2

The nurse is explaining the medication options available for pain relief during labor. The nurse realized the client needs further teaching when the client makes which statement? 1. Nalbuphine and prmethazine will give relief from pain and nausea during early labor 2. I can have an epidural as soon as I start contracting 3. If I have a cesarean I can have an epidural 4. If I have an emergency c section I may be put to sleep for the birth

2 (A client can have epidural when 3-4 cm dilated or active labor established. Waiting for this ensures the cervix is dilated to the point and epidural is less likely to halt labor contractions. Nalbuphine and promethazine are used to provide relief until the client is about 7 cm. If given after that time narcs may cause neonatal resp. depression. The majority of clients have an epidural or spinal for c section, unless its an emergency then general anesthesia may be used)

During a vaginal exam the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA -1 station 2. LSP -1 station 3. LMP +1 station 4. LSA +1 station

2 (The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mothers left posterior (LP) and buttocks at -1 station (1 cm above ischial spines))

Following an epidural and placement of the internal monitors a clients labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1 1/2 minutes. The uterine resting tone is >20 mm Hg with an abnormal FHR and pattern. Which action should the nurse take first? 1. Notify the HCP 2. Turn off the oxytocin infusion 3. Turn the client to her left side 4. Increase the maintenance IV fluids

2 (The client is experiencing uterine hyperstimulation from oxytocin. The first intervention should be to stop the oxytocin infusion which may be the cause of the long frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available O2 to be carried to the mother and fetus. When all other interventions are intitiated she should notify the HCP)

A multigravid client is admitted at 4 cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within 5 mins the client tells the nurse she feels like she needs to have a BM. The nurse should first: 1. have naloxone available in the birthing room 2. complete a vag exam to determine dilation, effacement, and station 3. prepare for birth 4. document the clients relief due to pain medication

2 (The feeling of needing to BM is commonly caused by the pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the clients signs and symptoms by checking to validate current effacement, dilation and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opiods, including respiratory depression. Documenting pain relief takes time away from the vag exam, preparing for birth and obtaining naloxone, The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documenting)

The HCP prescribes intermittent fetal heart rate monitoring for a 20 year old obese client at 40 weeks gestation in the first stage of labor. The nurse should monitor the fetal heart rate pattern at which interval? 1. every 15 minutes during latent phase 2. every 30 minutes during the active phase 3. every 60 minutes during the pushing phase 4. every 2 hours during the transition phase

2 (The first stage of labor is categorized into 3 phases: latent, active and transition. During the active stage of labor intermittent fetal monitoring is performed every 30 mintes to detect changes in the fetal heart rate such as bradycardia, tachycardia, or decelerations in a low risk labor. If complications develop, more frequent or continuous monitoring may be needed. During the latent phase intermittent monitoring is usually performed every hour because contractions during this time are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 minutes because the client is getting closer to the birth of the baby. Pushing occurs in stage II of labor and monitoring continues to occur every 5-15 minutes)

A client in labor received an epidural for pain mngmt. Before receiving the epidural the clients BP was 124/76. Ten minutes after receiving the epidural the clients BP is 98/56 and the mother is vomiting. Before calling the HCP the nurse should; 1. decrease the IV fluid rate 2. turn the client to her side 3. catheterize the client 4. perform a vag exam

2 (The nurse should turn the client to her side to reduce pressure on the abdominal aorta. IV fluid rate would be increased, not decreased. there is no info indicating the client has a full bladder or requires a vag exam)

A nurse is caring for a woman G1 P0 at 40 weeks in active labor. Assessments include cervix is 5cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of five uterine contractions and returns to baseline before the contraction ends. Based on this assessment, what action should the nurse take first? 1. position the client on her left side, and administer O2 via face mask 2. Document the findings on the clients chart and continue to monitor labor progress 3. Perform vaginal exam to rule out umbilical cord prolapse 4. notify the HCP immediately and prepare for emergency ceasarean section.

2 (The nurse would document these findings as early decels. Early decels are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decels do not require position change or O2 as they are not a sign of fetal distress. Variable decels are thought to be do to umbilical cord compression. Early decels are not emergent and do not require immed report to HCP or preparation for c-section)

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per min, during contractions. Immed after a contraction she complains of tingling in her fingers and some light headedness. Which of the following actions should the nurse take at this time? 1. assess the BP 2. Have the woman breath into a bag 3. Turn the woman on her side 4. check the FHR

2 (This client is showing signs of hyperventilation. the symptoms will likely subside if she rebreathes her exhalations.)

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? 1. excitement 2. loss of control 3. numbness of the legs 4. feelings of relief

2 (assessment findings indicate that the client is in the transition phase of labor. During this phase it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, N/V, and an urge to bear down are also common. Excitement is associated with the latent phase of labor. Numbness of the legs may occure when epidural anesthesia has been given. Feelings of relief generally occur during the second stage, when the client begins bearing down efforts.)

After the birth of a viable newborn a 20 year old primiparous client comments to her mother and the nurse about the baby. Which comment would the nurse interpret as a possible sign of potential maternal infant bonding problems? 1. He has got my funny looking ears! 2. I think my mother should give him the first feeding 3. He is a lot bigger than I expected him to be 4. I want to buy him a blue outfit to wear when we go home

2 (avoidance, hostility or low key passive behavior toward the baby may be a cue to potential bonding problems. The nurse should encourage the client to give the baby the first feeding to begin the bonding process. Expressions of disappointment with the baby gender may also signal problems with maternal-infant bonding, Comparing the babys features to her own indicates identification of the neonate as belonging to her, suggesting bonding. Comparing the actual neonate with the fantasized neonate is a normal maternal reaction. Wanting to buy a blue outfit indicates an interest in and connection with the neonate, and is a sign of bonding)

The nurse is assessing the internal fetal heart monitor tracing of an unmedicated full term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. baseline of 140 to 150 with V shaped decels to 120 unrelated to contractions 2. baseline of 140-150 with decels to 100 that mirror contractions 3. baseline of 140-142 with decels to 120 that return to baseline after the end of contractions 4. baseline of 140-142 with no obvious decels or acels.

2 (decels should mirror contractions,3. baselines with only a 2 beat variablility are minimal variability plus there are late decels that is related to uteroplacental insufficiency, and is an emergency. 4. You should be concerned when there is minimal variability 1. V shaped decels are variable but are related to cord compression and are NOT normal)

The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia admin, the nurse instructs the client to assume which position? 1. lithotomy 2. side lying 3. hands and knees 4. prone

2 (either sitting or side lying with shoulders parallel and legs slightly flexed.)

A primparous client who has just given birth to a healthy term neonate after 12 hours of labor holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which response? 1. dissapointment over the babys gender 2. grief over the ending of the pregnancy 3. a normal response to the birth .4. indication of postpartum blues

3 (birth can be a very emotional experience. )

The HCP plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks gestation for labor induction. After the amniotomy, the nurse should first? 1. monitor the clients contraction pattern 2. assess the FHR for 1 full minute 3. assess the clients temp and pulse 4. document the color of the amniotic fluid

2 (first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and or prolapsed cord, and and FHR of 100 bpm or less should promptly be reported to the HCP. A cord prolapse requires prompt birth by cesarean section. The clients contraction pattern should be monitored once labor has been established. The clients temp, pulse and RR should be assessed every 2-4 hrs after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern present)

After a lengthy labor process a primigravid client gives birth to a healthy newborn boy with moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? 1. It is typically seen with breech births 2. It usually lasts a day or two before resolving 3. It is typical when the brow is the presenting part 4. Surgical intervention may be necessary to allieviate pressure

2 (molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary)

A multigravid client has an extensive documented history of drug addiction. Her last reported use was 5 hrs ago. She is 2 cm dilated with contractions every 3 mins of moderate intensity. The HCP prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 mins of receiving the nalbuphine, the client states he thinks she is going to have her baby now. Of the drugs available at the time of the birth which should the nurse avoid using with this client in this situation? 1. lidocaine 1% 2. naloxone 3. local anesthetic 4. pudendal block

2 (naloxone would not be used in a client who has a history of drug addiction. Naloxone would abrubtly withdraw this woman from the drug she is addicted to as well as the nalbuphine. The withdrawal would occur within a few minutes of injection and if severe enough could jeopardize the mother and fetus. Lidocaine is a local anesthetic and numbs rather than decreases the effects of nalbuphine. The local anesthetic and the pudendal block are both appropriate for this birth but are used to numb the maternal perineum for birth.)

The nurse is assessing a client who states I think I am in labor. Which of the following findings would positively confirm the clients belief? 1. she is contracting q5 min x 60 seconds 2. her cervix dilated from 2-4 cm 3. her membranes have ruptured 4. the fetal head is engaged

2 (once the cervix begins to dilate the client is in true labor. )

A G1 P0 8 cm dilated is to receive pain med. The HCP has decided to order an opiate analgesic with a med that reduces some of the side effects of the analgesic. Which of the following meds would the nurse expect to be ordered in conjunction with the analgesic medication? 1. Seconal (secobarbital) 2. Phenergran (promethazine) 3. Stadol (butorphanol) 4. Tylenol (acetaminophen)

2 (phenergan acts to reduce N/V as well as to reduce allergic response. It acts as both antiemetic and antihistamine. )

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates teaching about spinal anesthesia has been understood? 1. The medication will be administered while I am in prone position 2. The anesthetic may cause a severe headache which is treatable 3. My BP may increase if I lie down too soon after the injection 4. I can expect immediate anesthesia that can be reversed very easiliy.

2 (spinal anesthesia is used less commonly today because of preference for epidural block. One of the adverse effects of spinal anesthesia is a spinal headache caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cold cloth to the forehead. keeping the client in a flat position or using a blood patch that can clot and seal off any further leakage of fluid. Hypotension is also a possible side effect. General anesthesia can be DC quickly. Epidural takes 1-2 hours to wear off. )

The nurse is assessing fetal station during a vaginal exam. Which of the following structures should the nurse palpate? 1. sacral promontory 2. ischial spines 3. cervix 4. symphysis pubis

2 (station is assessed by palpating ischial spines. Palpating the sacral promontory assessess the obstetric conjugate, not the fetal station. Palpating the cervix assesses the dilation and effacement. Palpating the symphysis pubis assesses the obstetric conjugate.)

A primigravid client is admitted to the labor area with ruptured membranes and contractions occuring every 2-3 minutes, lasting 45 seconds. After 3 hrs of labor, the clients contractions are now every 7-10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. The expected outcome of this drug is: 1. the cervix will begin to dilate 2cm/h 2. contractions will occur every 2-3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. 3. The dervix will change from firm to soft, efface to 40%-50% and move from a posterior to anterior position 4. contractions will be every 2 mins, lasting 60-90 seconds, with intrauterine pressure of 70 mmHg.

2 (the goal of oxytocin admin. in labor augmentation is to establish an adequate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions occurring every 2-3 mins, lasting up to 40-60 seconds, of moderate intensity with a palpable resting tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2cm/h is too rapid for the induction/augmentation process.)

A woman in the 2nd stage of labor has a strong urge to push. Which of the following actions by the nurse is appropirate at this time? 1. assess the FHR between contractions every 60 minutes 2. encourage the woman to grunt during contractions 3. assess the pulse and rr of the mother every 5 mins 4. position the woman on her back with her knees on her chest

2 (the woman should be encouraged to grunt during contractions, 1, during the 2nd stage of labor the FHR should be assessed every 5 mins. )

A woman who delivered her last infant by cesarean section is admitted to the hospital at term with contractions every 5 min. The HCP intends to have her undergo "a trial labor" The nurse explains to the client that: 1. labor will be stimulated with exogenous oxytocin until birth 2. The HCP needs more info to determine the presence of true labor 3. labor progress will be evaluated continually to determine appropriate progress for a vaginal birth 4. labor will be arrested with tocolytic agents after a 2 hr period even if no fetal distress is noted.

3 (A trial labor in this context means that a woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine to allow the labor to progress to birth. If there are indications labor is not progressing other means of birth are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 mins indicates true labor. If fetal distress is noted and an emergency cesarean cannont be done immed. tocolytic agents may be considered to stop contractions.)

A client is admitted at 30 weeks gestation with contractions every 3 mins. Her cervix is 1-2 cm dilated and 75% effaced. Following a 4g bolus dose, IV Mg SO4 is infusing at 2g/hr. How will the nurse know the medication is having the intended effect? 1. Contractions will increase in frequency leading to birth 2. The client will maintain a rr of 12 3. Contractions will decrease in frequency, intensity and duration 4. The client will maintain a BP of 120/80

3 (In this case the expected outcome is supression of contractions because of preterm labor. Mg. Sulfate is a smooth muscle relaxant used to slow and stop contractions and is one fo the most common tocolytic agenets in the US. Having contractions that lead to birth is not the intended effect of this drug when used for preterm labor. RR lower than 12 per min may indicate Mg. toxicity. Another use of Mg SO4 is to treat preeclampsia by preventing seizures and secondarily lowering maternal BP, however in this scenario, pre term labor not preeclampsia is being treated)

A nurse just performed a vaginal exam on a client in labor. The nurse palpates the babys buttocks as facing the mothers right side. Where should the nurse place the external fetal monitor electrode? 1. LUQ 2. LLQ 3. RUQ 4. RLQ

3 (RUQ because the babys back is facing the mothers right side and the sacrum is presenting, the fetal monitor should be placed RUQ)

A 39 year old client is admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate O2 during labor the nurse plans to encourage the client to: 1. breathe slowly after each contraction 2. avoid the use of analgesics for pain 3. remain in a side lying position with the head elevated 4. request local anesthesia for a vaginal birth

3 (Side lying helps with oxygenation and perfusion. In addition may use O2 mask, analgesics and sedative, diuretics, prophylactic antibiotics, and digitalis may be warranted. Breathing slowly may help with oxygenation but would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of pain, discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural may reduce cardiac workload by as much as 20%. Local anesthesia is only effective during the second stage of labor)

A multipara LOA station +3 who has had no pain medication during labor is now in stage 2. She states that her pain is 6 on a 10 scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. epidurals do not work well when the pain level is above level 5 2. I will contact the doctor to get an order for an epidural right away 3. The baby is going to be born very soon. It is really too late for an epidural 4. I will check the FHR. You can have an epidural if it is over 120

3 (The avg length of 2nd stage of labor for multiparous clients is about 15 mins. whereas the time for an epidural to be inserted and take effect is 20 mins. In addition the fetus in the scenario has already descended to 3+ station and is in the optimal position for delivery LOA. It is very likely this baby will be born in a few contractions. The nurse should encourage the client to continue pushing with contractions)

The primigravid client at +1 station and 9 cm dilated. Based on this data, the nurse should first: 1. ask the anesthesiologeist to increase epidural infusion rate 2. assist the client to push if she feels the need to do so 3. encourage the client to breathe through the urge to push 4. support family members in providing comfort measures.

3 (The urge to push is often present when the fetus reaches positive stations. This client does not have a cervix that is completely dilated, and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. Comfort measures are important for the client at this time but ar not at the highest priority for the nurse)

Approx 15 mins after birth of a viable term neonate a multiparous client has chills. What should the nurse do next? 1. assess the clients pulse rate 2. decrease the rate of the IV fluids 3. provide the client with warm blanket 4. assess the amount of blood loss

3 (a chill shortly after birth is a common normal occurrence. Warm blankets can help comfort the client. It has been suggested that shivering response is caused by a difference in internal and external body temps. A differnt theory proposes tat the woman is reacting to cells that have entered the maternal bloodstream through the placental site. Assessing the clients pulse rate will provide no futher info on the chill. Decreasing the IV rate will not influence the length of time the client trembles. Assessing blood loss is a standard of care at this point postpartum, but has no correlation with the chill)

While a nurse is caring for a multiparous client in active labor at 36 weeks gestation, the client tells the nurse "I think my water just broke" What should the nurse do first? 1. Turn the client to the right side 2. Assess the color amount and odor of the fluid 3. assess the FHR pattern 4. Check the clients cervical dilation

3 (after a spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical cord out of the birth canal. Sudden deceleration of the FHR commonly signifies cord compression and or prolaps of the cord, which would require immediate birth. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the client to the right side is not a priority action. However changing the clients position would be appropriate if variable decels are present. The nurse should assess the color, amount, and odor of the fluid but this can be done once the FHR is assessed and no problems detected. Cervical dilation should be checked but only after the FHR pattern is assessed.)

A full term client is admitted for induction of labor when admitted, her cervix is effaced 25% but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction? 1. nalbuphine 2. oxytocin 3. dinoprostone 4. betamethasone

3 (cervical ripening or creating a soft cervix that dilates to 2-3 cm, must occur before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include dinoprostone, misoporstol, and prostaglandin E2. Nalbuphine is a narc analgesic used in early labor and has no influence on the cervix. Betamethasone is a corticosteriod given to mature fetal lungs)

The HCP determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean birth with general anesthesia. Before the cesarean birth, the anesthesiologist prescribes cimetidine 300 mg PO. The nurse explains the purpose of giving cimetidine is to decrease: 1. incidence of bronchospasm 2. oral and respiratory secretions 3. acid level of the stomach contents 4. incidence of post op gastric ulcer

3 (cimetidine is prescribed by some anesthesiologists who will be giving a general anesthetic to reduce the level of acid in the stomach contents. altering the PH to reduce the risk of complications should aspiration of vomitus occur. Aspiration of vomitus is the 5th most common cause of maternal mortality. Most anesthesiologists insert an endotracheal tube to reduce the incidence of aspiration. Isoproterenol is used to decrease the incidence of bronchospasm. Atropine sulfate is administered to dry oral and nasal secretions. Although cimetidine is useful for gastric ulcer therapy, gastric ulcers are not a common effect associated with operative births)

During delivery the nurse notes the baby head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. flexion 2. internal rotation 3, extension 4. external rotation

3 (during extension the babys head is birthed. )

The HCP prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure what would the nurse include as the purpose? 1. assessment of the fetal hct level 2. increase in the strength of the contractions 3. increase in the FHR and variability 4. assessment of fetal position

3 (fetal scalp stimulation is commonly prescribed when there is decreased FHR variablility. Pressure is applied with the fingers to the fetal scalp through the dilated cervix. This should cause a tactile response in the fetus and increase the FHR and variability. However if the fetus is in distress and becoming acidotic, FHR acceleration will not occur. The fetal hct level can be measure by fetal blood sampling. Scalp stimulation does not increase the strength of contraction. However, it can increase FHR and variability. Fetal position is assessed by identifying the skull landmarks (sutures) during a vag exam.)

The cervix of a 15 year old primigravid client who has been admitted to the labor area is 2 cm. dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5-6 mins. Which intervention should the nurse recommend at this time? 1. resting in the right lateral recumbent position. 2. lying in the left lateral recumbent position 3. walking around in the hallway 4. sitting in a comfortable chair for a period of time

3 (most authorities suggest that a woman in early stage of labor should be allowed to walk. If she wishes as long as no complications are present. Birthing centers and single-room maternity units allow women considerable latitude without musch supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired she can rest in bed in the left lateral recumbent position or sit in a comfortable charir. Restin in the left lateral recumbent position improves circ to the fetus.)

The HCP has prescribed prostaglandin gel to be adminstered vaginally to a newly admitted primigravid client. Which finding indicates that the client has had a therapeutic response to the medication? 1. resting period of 2 minutes between contractions 2. normal patellar and elbow relfexes for the past 2 hours 3. softening of the cervix and beginning of effacement 4. leaking of clear amniotic fluid in small amounts

3 (prostaglandin gel may be used for cervical ripening before the induction of labor with oxytocin. It is usually administered by catheter or suppository or by vaginal insertion. Two or three doses are usually needed to begin the softening process. Common adverse affects include N/V, fever and diarrhea. Continuous fetal heart rate monitoring and close monitoring of maternal VS are necessary to detect subtle changes or adverse effects. Protaglandin gel usually does not initiate contractions; therefore, the rest period between contractions will be >2 mins. There is no need to assess reflexes based on prostaglandin use. Leaking of amniotic fluid is not caused by the use of this gel)

A multigravida in active labor is 7 cm dilated. The FHR baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next? 1. perform vag exam 2. notify the HCP of the decelerations 3. reposition the client and continue to evaluate HR 4. administer O2 via mask at 2L/min

3 (the cause of decelerations is cord compression. which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing vag exam will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, O2 should be initiated, but the rate should be 8-10L/min. Notifying the HCP should occur if turning the client and admin O2 does not relieve the decelerations)

When performing Leopold maneuvers the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. LUQ 2. RUQ 3. LLQ 4. RLQ

3 (the fetoscope should be placed on the LLQ for a fetus positioned in the LOA position. The fetal heart rate is heard thru the back)

The nurse enters a laboring clients room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. mentum anterior 2. sacrum posterior 3. occiput posterior 4. scapula anterior

3 (when a fetus is in the occiput posterior position, mothers freq complain of severe back pain, during each contraction the occiput is forced backward into the coccyx.)

A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks only Mandarin, and the interpreter is busy with an emergency situation. At her last vaginal exam the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client which response indicates that the client may be approaching birth? 1. fetal monitor shows late decels 2. The client begins to speak to her family in her native language 3. the fetal monitor strip shows early decels 4. The clients facial expression becomes animated

3 (when the fetal head is compressed early decels are seen as a vagal response occurs and the FHR decels and inversely mirrors the contraction. The response commonly occurs when the client is 9-10 cm dilated or pushing. If communication cannot be facilitated, early decels are one indicator that birth may be approaching. Late decels may occur at this time but indicate uteroplacental insufficiency rather than imminent birth. Facial expressions cannot be used as an indicator of imminent birth)

While a client is being admitted to the birthing unit she states, "My water broke last night, but my labor started 2 hrs ago". Which findings are a concern? Select all that apply; 1. maternal VS: T 99.5, HR 80, RR 24, BP 130/80 2. blood and mucous on perineal pad 3. baseline FHR of 140 bpm with a range between 110 and 160 with contractions 4. peripad stained with green fluid 5. client keeps stating "This baby wants out-he keeps kicking me"

3,4,5 (The range of FHR fluctuations of more than 25 bpm could indicate fetal distress. The green peripad fluid indicates meconium, which could be associated with fetal distress. Increased fetal activity during labor may also indidcate distress. The maternal VS noted and a perineal pad with blood and mucous are normal findings)

The nurse has obtained a urine specimen from a multiparous cient admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply: 1. assisting her to the bathroom 2. applying an external fetal monitor to obtain FHR 3. assessing her stage of labor 4. asking if she had back labor pains like this with any of her other birth experiences 5. allowing her support person to take her to the bathroom to maintain privacy 6. checking the degree of fetal descent

3,6 (The pressure form the fetus descending into the birth canal can cause the client to feel she needs to BM and could be near birth. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in birth in the bathroom. Applying a fetal monitor may reassure the nurse that the fetus is doing well; however it does not help to determine if the fetus is ready to be born, which is the higher priority in this situation. Regardless of the clients prior experience with back labor pain, the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the feeling of pressure with a BM.)

A nurse is coaching a woman in the 2nd stage of labor. Which of the following should the nurse encourage the woman to do? 1. hold her breath for twenty seconds during every contraction 2. blow out forcefully with every contraction 3. push between contractions until the fetal head is visible 4. take a slow cleansing breath before bearing down

4

A nurse determines that client is carring a fetus in the vertical lie. The nurses judgement should be questioned if the fetal presenting part is which of the following? 1. sacrum 2, occiput 3. mentum 4, scapula

4 ( a fetus in scapular presentation is in a horizontal lie)

A client at 33 weeks gestation is admitted in preterm labor. She is given betamethasone 12 mg IM every 24 hours x2. What is the expected outcome of this drug therapy? 1. the contractions will end within 24 hrs 2. The client will give birth to a neonate without infection 3. The client will give birth to a full term neonate 4. The neonate will be born with mature lungs

4 (Betamethasone is a corticosteroid that induces the production of surfactant. The pulmonary maturation that results causes the fetal lungs to maature more rapidly than normal Because the lungs are mature, the risk of respiratory distress in the neonate is lowered but not eliminated. Betamethasone also decreases the surface tension within the alveoli. Betamethasone has no influence on contractions or carrying the fetus to full term, it also doesnt prevent infection)

A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include; 1. prepare for birth, reposition the client, and begin pushing 2 perform sterile vaginal exam, increase IV fluids and apply O2 3. notify the HCP, explain findings to the client and begin pushing 4. reposition the client, apply O2 and increase fluids

4 (Late decels on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, O2, and IV fluids. A sterile vag exam is not indicated at this time. Late decels are not expected findings and do not indicate an imminent birth)

When developing a plan of care for a multigravid with class III heart disease the nurse should expect to assess the client frequently for which problem? 1. dehydration 2. N/V 3. iron deficiency anemia 4. tachycardia

4 (S/S of cardiac decomposition is the priority. Class III heart disease during preg. has a 25-50% mortality rate. These clients are markedly compromised with marked limitation of physical ability. They freq experience fatigue, palpitations, dyspnea, or anginal pain. A pulse rate >100 or a RR >25 may indicate cardiac decomposition that could result in cardiac arrest. Additional symptoms include peripheral edema, orthopnea, tachypnea, dyspnea, rales and hemoptysis)

The cervix of the primigravid client in active labor who received epidural anesthesia 4 hrs ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push the nurse should assess; 1. FHR variablility 2. cervical dilation again 3. status of the membranes 4. bladder status

4 (The bladder status should be monitored throughout the labor process, but especially before the client begins pushing. A full blader can impede the progress of labor and slow fetal descent. Because she has had an epidural anesthetic, it is most likely that the client is receiving IV fluids. contributing to a full bladder. The client also does not feel the urge to void because of the anesthetic. Although it is important to monitor membrane status and FHR variability throughout labor, this does not affect the clients ability to push There is no need to recheck cervical dilation because the increasing freq of exams can increase the clients risk for infection)

One hour ago a multipara was examined with the following results; 8cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced and +2 station 2. 9 cm dilated, 80% effaced and +3 station 3. 10 cm dilated, 90% effaced and +4 station 4. 10 cm dilated, 100% effaced and +5 station

4 (The cervix is fully dilated, and fully effaced and the baby is low enough to be seen through the vaginal introitus.)

What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia? 1. giving frequent sips of water 2. applying extra blankets for warmth 3. providing frequent perineal cleansing 4. offering encouragement and support

4 (The client is in the transition phase of the first stage of labor. During this phase the client needs encouragement and support because this is a difficult and painful time, when contractions are especially strong. Usually the client finds it difficult to maintain self control. Everything else seems secondary to her as she progresses into the 2nd stage of labor. Although ice chips may be given, typically the client does not desire sips of water. Labor is hard work. Generally the client is perspiring and does not desire additional warmth. Frequent perineal cleansing is not necessary unless there is excessive amniotic fluid leaking)

Two hours ago a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently the client is experiencing N/V, a slight chill with perspiration beads on her lip and extreme irrittability. The nurse should first: 1. warm the temp of the room by a few degrees 2. increase the rate of IV fluid admin. 3. obtain a prescription for an IM antiemetic medication 4. asssess the clients cervical dilation and station

4 (The nurse should assess the clients cervical dilation and station because the clients symptoms are indicative of the transition phase of labor Multiparous clients can proceed 5-9 cm/hr during the active phase of labor. Warmin the temp of the room is not helpful because the client will soon be ready to begin expulsive pushing. Increasing the IV fluid rate is not warranted unless the client is experiencing dehydration. Admin of an antiemetic at this point in labor is not warranted and may result in neonatal depression should a rapid birth occur)

A primigravid client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, what would be the best position fo the client to assume? 1. dorsal recumbent 2. lithotomy 3. hands and knees 4. squatting

4 (anatomically the best position is the squatting position because it enhances pelvic diameters and allows gravity to assist in the expulsion stage of labor. This position also provides for natural pressure anesthesia as the presenting part presses on the stretched perineum.. If the client is extremely fatigued from a lengthy process she may prefer the dorsal recumebent. However this position is not considered the best anatomical position. The lithotomy position may be ineffective and uncomfortable for the client who is ready to push. The hands and knees position may help to alleviate some back pain, however, this position can cause discomfort to the arms and wrists and is tiring over a period of time)

A 21 year old primigravid client at 40 weeks gestation is admitted to the hospital in active labor the clients cervix is 8cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? 1. urinary retention 2. hyperventilation 3. ineffective coping 4. pain

4 (during transition, contractions are increasing in frequency and duration and intensity. The most appropriate nursing problem is pain related to strength and duration of the contractions. Insufficient information is provided in the scenario to support the other listed nursing diagnoses. Urinary retention would be appropriate if the client had a full bladder and was unable to void. Hyperventilation might apply if the client was breathing too rapidly, but there is no evidence this is occuring. Ineffective coping might apply if the client said "I cannot do this" or something similiar)

The nurse is caring for a G2 T1 P0 A0 L1 client at term. The client is completely effaced, dilated to 2 cm, with contractions every 3 mins. lasting 45 seconds. The client is asking for an epidural to make her more comfortable. Indicate the appropriate response by the nurse 1. we can not give epidurals until you are 5-6 cm dilated. There is IV medication available if you would like it now 2. You cannot have an epidural until your membranes have ruptured 3. Your contraction pattern is slow at this point and will need to accelerate before you can have your epidural 4. It is too early in labor for the epidural, but you can have IV medication to keep you comfortable until you have dilated 1-2 cm more

4 (epidurals are given when labor is established, usually at 3-4 cm dilation. The effect of the epidural should be that labor will continue and not be slowed down by the admin of the epidural. The use of an epidural is not correlated with rupture of membranes. The contraction pattern for this client is adequate, not slow, and considered normal for 2 cm dilation. Epidurals are given at 3-4 cm dilation, and if there is medication available it can be given to make the client comfortable until an epidural can be given)

The nurse is caring for a full term nonmedicated primiparous client who is in the transition stage of labor. The client is writhing in pain and saying "help me, help me" Her last vag exam 1 hr ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? 1. help the client thru contractions until a narcotic can be given 2. palpate the bladder to see if it has become distended 3. ask the client for suggestions to make her more comfortable 4. perform a vag exam to determine if the client is fully dilated

4 (transition is the most difficult time of the labor process. Often when clients are tired, pain becomes more intense. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing. Performing a vag exam would give this answer. The use of narc meds is discouraged at this stage as they can lead to resp depression in the neonate. Palpating the bladder is an important intervention but not the highest priority as it was done less than an hour ago. Since the nurse has correctly completed the most logical steps asking for the clients input would certainly be in order but not the highest priority intervention.)