intrapartem part 2
A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?
Report the time of last food intake to the health care provider.
A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which?
1 cm above the ischial spines
The nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is in which position?
1 cm above the ischial spines
The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which?
Characteristics of contractions
A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?
Check the fetal heart rate.
The nurse is caring for a client in labor. The nurse reviews the health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. The nurse understands that the action of this medication is to have which effect?
Decrease pain.
The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?
Decreased periods of uterine relaxation between contractions
A primigravida's membranes rupture spontaneously. Which action should the nurse take first?
Determine the fetal heart rate.
A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?
Determine the parents' desires for contact with the newborn.
The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?
Effleurage is light stroking of the abdomen to facilitate relaxation during labor.
A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?
Encourage the client to discuss her concerns and desires regarding anesthesia options.
The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitude?
Excitement
The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?
Fear about what is happening
A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which finding would indicate a need to contact the registered nurse (RN)?
Fetal heart rate of 180 beats per minute
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?
Fetal tachycardia
Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal?
It is pale, straw-colored with flecks of vernix.
A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse include in the plan of care?
Maintain complete bed rest, monitor IV fluid intake, and monitor the fetal heart rate.
The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse should include which in the plan of care?
Maintain continuous electronic fetal monitoring.
The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?
Provide pain relief measures.
A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure?
A cesarean birth
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?
A manual pelvic examination
The nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?
Pain level is "4" while a progressive labor pattern continues.
A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor?
Administer oxygen as prescribed.
The nurse is assigned to assist in caring for a client in labor. The nurse would determine that which sign/symptom would least likely indicate dystocia?
Progressive changes in the cervix
The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take?
Continue to assess vital signs and fetal heart rate the same as before the nerve block.
A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?
Contraction stress test
The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?
McRoberts' maneuver
The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which as least likely necessary for the care of this client?
Measuring the fundal height
The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
Minus (-) 1 station
The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?
Monitor the fetal heart rate.
The nurse is assigned to care for a client experiencing dystocia. Which would be the highest priority in planning care?
Monitoring for changes in the physical and emotional condition of the mother and fetus
The nurse should prepare to give a prescribed oxytocic medication after delivery of which?
Placenta
At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action?
Prepare the client for a cesarean delivery.
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?
Presence of accelerations
During the intrapartum period, the nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which result?
Prevent dehydration and hypoxemia.
The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?
Side-lying
The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?
White blood cell count of 35,000 cells/mm3
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?
Notify the registered nurse (RN).
The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.
2. The fetus is in the breech position. 3. Lesions are present on the perineum. 5. The fetus is not settled into the pelvis.
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which is the primary purpose of this action?
Assist in preventing dehydration and hypoxemia.
A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete rupture occurs?
Decreasing blood pressure
The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?
Determine the fetal heart rate.
The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal?
Prevent dehydration and hypoxemia.
The nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding which is the nurse's priority action?
Stop the oxytocin infusion.
The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?
Supine position with a wedge under the right hip
When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply.
1. One vein 4. Two arteries
The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document that the FHR is normal if which result is noted?
150 beats per minute
Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.
2. Constant fever of 101° F 4. Persistent pelvic heaviness 5. Foul-smelling vaginal discharge
The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta?
Pull gently on the cord as the mother bears down.
A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicates to the nurse the presence of concealed bleeding?
Increase in fundal height
