High-Risk Intrapartum (test #3) Nov 12

A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask.

1. Assess the maternal pulse while listening to the fetal heart rate.

The doctor writes the following order for a 31-week-gravid client with symptomatic placenta previa: Weigh all vaginal pads and estimate blood loss. The nurse weighs one of the client's saturated pads at 24 grams and a dry pad at 4 grams. How many milliliters (mL) of blood can the nurse estimate the client has bled? Calculate to the nearest whole number. __________ mL.

20 mL of blood ( 1 gram per mL)

To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which of the following medications? 1. Antacids. 2. Tranquilizers. 3. Antihypertensives. 4. Anticonvulsants.

1. Antacids

A laboring client has been diagnosed with a hypercoagulability syndrome. Which of the following medications would the nurse expect the primary health care provider to order? 1. Heparin ( heparin) 2. Coumadin (warfarin) 3. Amicar ( aminocaproic acid) 4. DDAVP (desmopressin acetate)

1. Heparin ( heparin) Heparin would be preferred because it does not cross the placenta like Coumadin (warfarin) would

A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.

1. Coughing and deep breathing. Because the client will have a cesarean section with anesthesia, the woman should be taught coughing and deep-breathing exercises for the postoperative period.

A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client?

1. Diarrhea and back pain. A common side effect of Cytotec is diarrhea and labor contractions are often first felt in the back.

The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus?

1. Late decelerations.

The fetal heart rate pattern of a client in active labor shows moderate variability with mild decelerations. The nurse makes which of the following interpretations of the pattern 1. Category I pattern requiring tocolytic medication administration 2. Category II pattern requiring lateral positioning , oxygen administration via face mask , and IV fluid bolus. 3. Category III pattern requiring lateral positioning , oxygen administration via face mask , IV fluid bolus, and amnioinfusion. 4. Category IV pattern requiring immediate termination of labor

2. Category II pattern requiring lateral positioning , oxygen administration via face mask , and IV fluid bolus.

The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The nurse should question the order for which of the women?

2. Multigravida with late decelerations. This client's fetus is already showing signs of fetal distress. Induction increases the risk of fetal injury.

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate?

2. Notify the physician of her request.

A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1. Contraction pattern is every 3 min × 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.

2. Fetal monitor tracing shows late decelerations. Late decelerations are indicative of uteroplacental insufficiency and indicate fetal distress. It is inappropriate to administer a central nervous system (CNS) depressant to the mother at this time.

A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time?

3. Assess the fluid with nitrazine and see if the paper turns blue.

The nurse is assessing the Bishop's score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.

3. Cervical dilation 4. Fetal station 5. Cervical position

A client with an internal fetal monitor catheter in place has just received IV butorphanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Diminished short- and long-term variability. 4. Accelerations after contractions.

3. Diminished short- and long-term variability. would result from Stadol administration.

A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.

3. Duration of contractions of 130 seconds. The duration of the contractions is prolonged. The baby will be deprived of oxygen.

A client who's baby is exhibiting signs of erythroblastosis fetalis, is admitted to the labor and delivery unit. The nurse would expect to see which of the following fetal heart monitoring tracings? 1. marked fetal heart variability 2. prolonged fetal heart accelerations 3. sinusoidal fetal heart patterns. 4. periodic variable decelerations

3. sinusoidal fetal heart patterns.

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following?

3.Cord compression. The contractions described in the scenario result from cord compression (variable decelerations).

A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first?

4. Check the fetal heart rate of a client who just ruptured membranes.

A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).

4. Terbutaline (Brethine) is a smooth, muscle-relaxing agent. It would be administered prior to an external version.

A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The Bishop's score is now 10. Which of the following actions by the nurse is appropriate?

4. Monitor for onset of labor. The nurse should monitor this client for the onset of labor.

A client is in active labor. Which of the following assessments would warrant immediate intervention?

4. fetal scalp pH of 7.19 is indicative of an acidotic fetus.

A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals?

2. delivery of a healthy baby.

The nurse is admitting a 38-week-gestation client in labor. The nurse is unable to find the fetal heartbeat with a Doppler. Which of the following comments by the nurse would indicate that the nurse is in denial? 1. "I'll keep trying until I find the heartbeat." 2. "I am sure it is the machine. If I change the battery, I'm sure it will work." 3. "I am so sorry. I am not able to find your baby's heartbeat." 4. "Sometimes I really hate these machines."

1. "I'll keep trying until I find the heartbeat."

The nurse in the obstetrician's office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day.

1. 38-year-old in an abusive relationship. This client is high risk for PTL because she is over 35 years of age and in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation A previous preterm delivery places a client at increased risk of preterm labor. 5. 22-year-old who smokes 2 packs of cigarettes every day. A woman who smokes cigarettes is at high risk for preterm labor.

A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.

1. A fetal heart rate

A nurse has been assigned to circulate during the cesarean section of triplets. Which of the following actions should the nurse take before the birth of the babies? Select all that apply. 1. Count the number of sterile sponges. 2. Document the time of the first incision. 3. Notify the pediatric staff. 4. Perform a sterile scrub. 5. Assemble the sterile instruments.

1. count the sterile sponges. This is done together with the scrub nurse. 2. document the time of the first incision. 3. notify the pediatric staff. There should be one resuscitation team assembled in the delivery room for each baby that will be delivered.

A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sad. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.

1. crying and sad.

A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diagnosis of acute oligohydramnios. The nurse must carefully observe this client for signs of which of the following? 1. Fetal distress. 2. Dehydration. 3. Oliguria. 4. Jaundice.

1. fetal distress.

A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.

1. hepatitis B 4. group B streptococcus 5. HIV/AIDS

The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? 1. Risk for impaired skin integrity. 2. Risk for body image disturbance. 3. Risk for impaired parenting. 4. Risk for ineffective sexuality pattern.

1. risk of impaired skin integrity.

In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations.

2. Meconium-stained fluid.

The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective?

2. A frequency pattern of every 3 minutes is ideal.

A laboring woman, who has developed an apparent amniotic fluid embolism, is not breathing and has no pulse. In addition to calling for assistance, which of the following actions by the nurse, who is alone with the patient, is appropriate at this time?

2. Chest compressions at a depth of at least 2 inches.

The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section: Risk for ineffective individual coping related to the emergency procedure. Which of the following nursing interventions would be appropriate in relation to this diagnosis? 1. Apply antiembolic boots bilaterally. 2. Explain all procedures slowly and carefully. 3. Administer an antacid per MD orders. 4. Monitor the FH and maternal vital signs.

2. explain all procedures slowly and carefully.

An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.

2. hemorrhage.

The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order?

Primigravida with a transverse lie. Induction is contraindicated in transverse lie.

A woman, 402⁄7 weeks' gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units oxytocin (Pitocin) to be diluted in 1,000 mL D51⁄2 NS. The order reads: Administer oxytocin IV at 0.5 milliunits per min. Calculate the drip rate for the infusion pump to be programmed. Please calculate to the nearest whole number. __________ mL/hr.

3 mL/hr.

The health care practitioner performed an amniotomy 5 minutes ago on a client, G3 P1011, 40 weeks' gestation, -4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green-tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is post-term. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.

3. the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelerations are seen on the FH monitor.

Which of the following situations in a fully dilated client is incompatible with a forceps delivery? Select all that apply. 1. Maternal history of asthma. 2. Right occiput posterior position at +4 station. 3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute at -1 station. 5. Maternal history of cerebral palsy.

3. transverse fetal lie is physically incapable of delivering vaginally. 4. Fetal heart rate of 60 beats per minute at -1 station. The baby has yet to engage. This baby would likely be delivered by cesarean section for prolonged fetal distress.

A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see?

Confusion, drowsiness, and vomiting. These are the classic signs of water intoxication.

Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply.

Women receiving oxytocin for induction. Woman with meconium-stained fluid.

A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1. Begin oxytocin drip rate at 0.5 milliunits/min.

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply.

1. Breech presentation. 2. Station -3. 5. transverse lie,

A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).

1. Calcium gluconate.

The nurse is admitting four full-term primigravid clients to the labor and delivery unit. The nurse requests pre-cesarean section orders from the health care practitioner for which of the clients? The client who has: Select all that apply. 1. Cervical cerclage. 2. FH 156 with beat-to-beat variability. 3. Maternal blood pressure of 90/60. 4. Full effacement. 5. Active herpes simplex 2

1. Cervical cerclage, a stitch encircling the cervix, is incompatible with vaginal delivery. 5. Active herpes simplex 2 is an absolute indicator for a cesarean delivery.

A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes × 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take?

1. Check dilation and effacement.

The nurse is caring for four women who are in labor. The nurse is aware that he or she will likely prepare which of the women for cesarean delivery? Select all that apply. 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Fetus has been diagnosed with meningomyelocele. 4. Client is hepatitis B surface antigen positive. 5. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5:1.

1. Fetus is in the left sacral posterior position. The baby in the LSP position is in a breech presentation. Most breech babies are delivered by cesarean section. 3. Fetus has been diagnosed with meningomyelocele. The meningomyelocele sac could easily rupture during a vaginal delivery. When a fetus has been diagnosed with the defect, a cesarean is usually performed.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

1. Increasing fundal height measurements. Fundal height is increase approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour.

A baby is entering the pelvis in the vertex presentation and in an extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. RScT (right scapular transverse). 4. ROP (right occiput posterior).

1. LMA position(left mentum anterior). is consistent with that information.

A woman, 32 weeks' gestation, contracting every 3 min × 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.

1. Low urinary output should be carefully monitored.

A woman in active labor received Nubain (nalbuphine hydrochloride) 14 mg IV for pain relief. One half hour later her respirations are 8 rpm. The nurse reports the respiratory rate to the physician. Which of the following medications would be appropriate for the physician to order at this time? 1. Narcan (naloxone). 2. Reglan (metoclopramide). 3. Benadryl (diphenhydramine). 4. Vistaril (hydroxyzine).

1. Narcan (naloxone).

A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes +1. 4. Blood pressure 140/90.

1. Pink-tinged urine. This client has likely developed disseminated intravascular coagulation (DIC). The nurse should watch for pink-tinged urine.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first?

1. Put the client in the knee-chest position.

A physician has given a nurse a verbal order to apply cricoid pressure. Which of the following is the likely indication for the action? 1. Forceps delivery. 2. Endotracheal tube insertion. 3. Epidural insertion. 4. Third stage of labor.

2. Endotracheal tube insertion Cricoid pressure is indicated during endotracheal intubation.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first?

1. Turn off the oxytocin infusion. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip.

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion?

2. Change in fetal heart rate from 128 to 102 bpm. The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin is stopped.

During a vaginal delivery, the obstetrician declares that shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2. Flexing the woman's hips/thighs sharply toward her abdomen. (called McRoberts' maneuver.)

A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate?

2. Follow standard infectious disease precautions. Standard precautions are indicated in this situation.

A physician has notified the labor and delivery suite that four clients will be admitted to the unit. The client with which of the following clinical findings would be a candidate for an external version? 1. +3 station. 2. Left sacral posterior position. 3. Flexed attitude. 4. Rupture of membranes for 24 hours.

2. LSP (Left sacral posterior position.) is a breech presentation. It may be appropriate for a physician to perform an external version prior to this delivery.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time?

2. Maternal temperature is the highest priority.

A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time?

2. Notify the practitioner. Sinusoidal patterns are related to Rh isoimmunization, fetal anemia, severe fetal hypoxia, or a chronic fetal bleed. They also may occur transiently as a result of Demerol (meperidine) or Stadol butorphanol) administration. As this client has just been admitted, medication administration is not a likely cause. The health care practitioner should be notified.

The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2. Pad the client's bed rails and headboard.

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.

2. Petechiae. develop when a client is thrombocytopenic, one of the signs of HELLP syndrome. 3. Jaundice. Hyperbilirubinemia develops when red blood cells hemolyze, one of the changes that may develop as a result of liver necrosis. Jaundice is a manifestation of hyperbilirubinemia.

The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.

2. Risk for fetal injury related to possible intrauterine hypoxia.

The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick count assessments.

2. Signs of preterm labor. Positive fetal fibronectin levels are seen in clients who deliver preterm.

A physician writes the following order—Administer ampicillin 1 g IV q 4 h until delivery—for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacterium is sexually transmitted. 4. The bacterium causes puerperal sepsis.

2. The baby is at high risk for neonatal sepsis. from vertical transmission of the bacteria.

Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor?

2. The client will exhibit normal breathing function at discharge.

Induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action?

2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. The practitioner should increase the dosage of oxytocin at a minimum time interval of 30 minutes.

The nurse is monitoring a woman, G2 P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; -3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; -3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1. Labor is progressing well. 2. The woman is likely carrying a macrosomic fetus. 3. The baby is in fetal distress. 4. The woman will be in second stage in about five hours.

2. The woman is likely carrying a macrosomic fetus. Because the presenting part is not descending into the birth canal,

A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time?

2. Vaginal examination is contraindicated.

The primary practitioner for a 38 1/7 week gravid client calls the labor and delivery suite to schedule an induction for the next day. The client is having no medical or pregnancy complications. Which of the following responses by the nurse would be appropriate? 1. "At what time would you like to begin the induction?" 2. "What is the client's Bishop score?" 3. "I am sorry, but the client will not be able to be induced tomorrow." 4. " I will have the prostaglandin induction medication prepared."

3. "I am sorry, but the client will not be able to be induced tomorrow."

There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture?

3. Age 25, G4 P3003, last delivery by cesarean section. A woman, no matter what her age, who has had a previous cesarean section is at risk for uterine rupture.

A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1. Administer betamethasone (Celestone) 12 mg IM daily times 2. 2. Maintain strict bed rest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 mL/hr).

3. An order to assess cervical dilation should be questioned.

A 30-year-old G2 P0010 in preterm labor is receiving nifedipine (Procardia). Which of the following maternal assessments noted by the nurse must be reported to the health care practitioner immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2,000 mL.

3. Audible rales

A woman who is hepatitis B-surface antigen-positive is in active labor. Which action by the nurse is appropriate at this time?

3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG.

The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Spinal clients complain of nausea and vomiting.

3. Epidurals do not fully sedate the motor nerves. Epidural clients are capable of moving their lower extremities even when fully pain-free.

The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL. 2. G2 P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2 P1001, 39 weeks, Rh-negative, today's hematocrit 31%.

3. G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. This is the nurse's priority.

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min × 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

3. Magnesium sulfate a tocolytic agent, It would be appropriate for this medication to be administered at this time.

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Platelets 75,000. Low platelets are consistent with the diagnosis of HELLP syndrome.

A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes?

3. Prepidil is administered endocervically.

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3. Presence of abdominal pain. The most common difference between placenta previa and placenta abruption is the absence or presence of abdominal pain.

Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 120 with variable decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred?

3. Prolapsed cord. The drop in fetal heart rate with variable decelerations indicates that the cord has likely prolapsed.

After a multiparous woman has been in active labor for 15 hours, an ultrasound is done. The results state that the obstetric conjugate is 10 cm and the suboccipitobregmatic diameter is 10.5 cm. Which of the following labor findings is related to these results? 1. Full dilation of the cervix. 2. Full effacement of the cervix. 3. Station of -3. 4. Frequency every 5 minutes.

3. Station of -3. A high station is consistent with the data in the scenario.

A woman has been in the second stage of labor for 21/2 hours. The fetal head is at +4 station and the fetal heart is showing mild late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the woman to push between contractions. 3. Assess the fetal heart rate after each contraction. 4. Advise the woman to refuse the use of forceps.

3. The FH should be assessed after each contraction

A client, G3 P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman?

3. The baby may develop thrush after delivery. Thrush is the term given to oral candidiasis, which the baby may develop after delivery.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.

3. The client's bladder should be palpated.

A nurse is caring for a gravid client who is G1 P0000, 35 weeks' gestation. Which of the following would warrant the nurse to notify the woman's health care practitioner that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.

3. The dilation of 3 cm is indicative of preterm labor. 4. A cervical length of 2 cm is indicative of preterm labor.

A woman being induced with oxytocin (Pitocin) is contracting every 3 min × 30 seconds. Suddenly the woman becomes dyspneic and cyanotic and begins to cough up bloody sputum. Which of the following nursing interventions is of the highest priority?

3. The nurse's priority action is to administer oxygen.

The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as:

3. The results are equivocal, warranting further sampling.

An anesthesiologist informs the nurse that a woman scheduled for cesarean section will have the procedure under general anesthesia with postoperative patient-controlled analgesia rather than under continuous epidural infusion. Which of the following would warrant this decision? 1. The woman has a history of drug addiction. 2. The woman is allergic to morphine sulfate. 3. The woman is a thirteen-year-old adolescent. 4. The woman has had surgery for scoliosis.

4. A history of scoliosis surgery is a contraindication for epidural anesthesia.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.

4. A serum magnesium level of 9 g/dL is dangerously high. The health care practitioner should be notified.

A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 3 min × 90 sec to q 2 min × 60 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.

4. Change in fetal heart rate from 160 bpm to 210 bpm. When the fetal heart rate pattern is greater than 200 bpm, the medication should be stopped. 5. Change in the amniotic sac from intact to ruptured. Terbutaline is contraindicated when the membranes have ruptured prematurely.

A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output is 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.

4. Client has no grand mal seizures.

A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin?

4. Contraction frequency of 1 minute. A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication.

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G2 P0010, 27 weeks' gestation. 2. G3 P1101, 17 years of age. 3. G4 P2101, cancer survivor. 4. G5 P1211, cocaine abuser.

4. G5 P1211, cocaine abuser. Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruptions.

The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take?

4. Increase the intravenous infusion rate. Increasing the IV rate helps to improve perfusion to the placenta.

A woman, G3 P2002, 42 weeks' gestation, is admitted to the labor suite for induction. A biophysical profile (BPP) report on the client's chart states BPP score of 6 of 10. The nurse should monitor this client carefully for which of the following? 1. Maternal hypertension. 2. Maternal hyperglycemia. 3. Increased fetal heart variability. 4. Late fetal heart decelerations.

4. Late fetal heart decelerations. secondary to a postmature placenta.

A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station -2. 2. 38 weeks' gestation. 3. Reactive NST. 4. Previous cesarean section.

4. Previous cesarean section is a contraindication for external version.

A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate?

4. Provide the woman with ongoing labor support. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated.

Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia is an obstetric emergency.

A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time?

4. monitor the woman's labor.

A pregnant woman, G3 P2002, had her two other children by cesarean section. Which of the following situations would mandate that this delivery also be by cesarean? 1. The woman refuses to have a regional anesthesia. 2. The woman is postdates with intact membranes. 3. The baby is in the occiput posterior position. 4. The previous uterine incisions were vertical.

4. The previous uterine incisions were vertical.

A nurse is monitoring a client who is receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make to prevent a serious complication related to the procedure? 1. Color of the amniotic fluid. 2. Maternal blood pressure. 3. Cervical effacement. 4. Uterine resting tone.

4. The uterine resting tone

A client, G3 P2002, is immediately post external version. The nurse monitors this client carefully for which of the following? 1. Decreased urinary output. 2. Elevated blood pressure. 3. Severe occipital headache. 4. Variable fetal heart decelerations.

4. variable fetal heart decelerations.

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse to make at this time?

4."Have you felt the baby move since the membranes broke?" The most important information needed by the nurse should relate to the health and well-being of the fetus. Fetal movement indicates that the baby is alive.

An insulin-dependent diabetic is in active labor. The physician has written the following order: Administer regular insulin 5 units per hour via IV pump. The insulin has been diluted as follows: 50 units/500 mL normal saline. At what rate should the nurse set the pump? Please calculate to the nearest whole number. __________ mL/hr.

50 mL/hr

A preterm labor client, 30 weeks' gestation, who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."

3. "To help to mature your baby's lungs." Decadron is a steroid that hastens the maturation of the fetal lung fields.

Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A client with cardiac disease. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order.

During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? 1. Into the musculature of the buttock. 2. Through the urinary meatus. 3. Through the rectal sphincter. 4. Into the head of the clitoris.

3. A fourth-degree laceration extends through the rectal sphincter.

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications?

3. Abruptio placentae.

A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm3 and a hematocrit of 29%. Her lab values 1 week earlier were platelet count 200,000 cells/mm3 and hematocrit 37%. Which additional abnormal lab value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).

4. Elevated alanine transaminase (ALT).