intrapartem

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms would indicate that the client's bleeding is caused by placenta previa? Select all that apply.

2. Bright red vaginal bleeding 3. Lack of uterine contractions

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply.

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated?

8 to 10 cm

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?

A change in the uterine contour

The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond?

Administer oxygen via face mask to the mother.

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem?

Anxiety and fear

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problems should the nurse expect to note on the plan of care?

Anxiety related to a slow progress of labor

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest

The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time?

Continue monitoring the client because the data reflect acceptable progress.

The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?

Continue to monitor the client.

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?

Fear of losing control

Which would be the appropriate method to use to deliver the placenta after a precipitate delivery?

Gently guide the placenta out after a spontaneous separation.

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?

Intravenous (IV) supplies

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?

Keep the client in a side-lying position.

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?

Lateral Sims'

The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status

The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which action at this time?

Notify the registered nurse of a possible maternal infection.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse?

Respirations of 10 breaths per minute

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time?

Rest between contractions

The nurse is caring for a woman in the labor room. The health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?

Resting interval of 50 seconds

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse would place the client at risk for uterine rupture?

Shoulder dystocia

The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which?

Signs of shock

the nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC?

Swelling of the calf of one leg

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?

When was the last time the client ate or drank?

the nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?

"My cervix is completely dilated."

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?

"What an efficient way to record my baby's heart rate."

The advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply.

1. Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply.

1. Encourage frequent urination. 3. Continue maternal and fetal assessments. 4. Review breathing and relaxation techniques.

The nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.

1. Signs of fetal distress 2. High level of maternal anxiety 3. Failure of the fetus to descend

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor which criteria?

All vital signs, especially heart rate and blood pressure

A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort?

Assist the client to ambulate in the room.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

Baseline fetal heart rate

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, which action should the nurse take initially?

Determine the maternal and fetal vital signs.

For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes lasting 60 to 70 seconds and strong to palpation. She is dilated 2 cm and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?

Hypertonic

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?

Maternal vital signs

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?

Oozing from injection sites

A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate?

Prepare the client for a cesarean delivery.

If a precipitate delivery is imminent, which would be the appropriate nursing action?

Put on sterile gloves, and gently guide the baby's head and shoulders out.

The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose?

Reduce the risk of injuring the bladder during the surgery.

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock?

Restlessness and agitation

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?

The client feels hopeless about the situation.

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?

Administering oxygen via face mask

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?

Change in uterine shape

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition?

Placental separation

The nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which condition becomes apparent?

Decreased periods of uterine relaxation between contractions

The nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

Changes in the shape of the uterus

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?

Uterine tenderness on palpation

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

Have the client empty her bladder.