Intrapartum

Contraction stress test

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?

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

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?

8 to 10 cm As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

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?

Support the mother in her reaction to the newborn.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

1.Exertion 2.Infection 3.Hypoxemia 4.Dehydration

During the intrapartum period, the nurse is caring for a laboring client diagnosed with sickle cell disease. The nurse recognizes that which conditions are most likely to lead to a sickling crisis? Select all that apply.

A manual pelvic examination

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?

3.Bearing down with contractions 4.Making expiratory vocalizations 5.Changing body positions frequently

The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply.

baseline fetal heart rate

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?

sidelying position

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?

"My cervix is completely dilated."

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?

Uterine tenderness on palpation

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 placentae is accompanied by which additional finding?

Monitoring for changes in the physical and emotional condition of the mother and fetus

The nurse is assigned to care for a client experiencing dystocia. Which is the highest priority in planning care?

White blood cell count of 35,000 mm3

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?

Administer oxygen as prescribed.

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?

Rest between contractions.

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

Check the fetal heart rate.

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?

Encourage the client to discuss her concerns and desires regarding anesthesia options.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?

Respirations of 10 breaths per minute

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?

Increased efficiency of contractions

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?

1 cm above the ischial spines

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?

Determine the parents' desires for contact with the newborn.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Anxiety and fear

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?

Contractions typically occur in the latent phase of labor. Contractions occurring every 2 minutes, lasting 70 seconds. Contraction force is felt in the midsection of the uterus rather than the fundus.

For the previous 4 hours, a client in labor has been experiencing hypertonic labor as documented by the primary health care provider. The nurse recognizes which findings to be characteristic of this type of labor? Select all that apply.

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

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

Excitement Alertness

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 attitudes? Select all that apply.

complete bed rest (CBR) rational: risk of prolapsed cord

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?

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

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

Stop the oxytocin infusion.

The nurse caring for a client who is receiving oxytocin 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?

Supine position with a wedge under the right hip

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?

1.A trickle or gush of blood escapes from the introitus 2.The umbilical cord lengthens 3.Changes in the shape of the uterus

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

Document the findings and continue to monitor the fetal patterns.

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?

Have the client empty her bladder.

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?

Bright red vaginal bleeding Soft, relaxed, nontender uterus

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

Fear of losing control

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?

Effleurage is light stroking of the abdomen to facilitate relaxation during labor.

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?

Progressive changes in the cervix

The nurse is assigned to assist in caring for a client in labor. The nurse determines that which sign/symptom would least likely indicate dystocia?

Intravenous (IV) supplies

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?

Keep the client in a side-lying position.

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?

A change in the uterine contour

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?

Shoulder dystocia

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

Fear about what is happening

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?

Determine the maternal and fetal vital signs.

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

Maternal vital signs

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?

1."Leopold's maneuvers are used to determine fetal position." 2."Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 3."Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply.

Prevent dehydration and hypoxemia.

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?

Pain level is "4" while a progressive labor pattern continues.

The nurse is evaluating the effectiveness of meperidine hydrochloride 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?

Administer oxygen via face mask to the mother.

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?

Fetal tachycardia

The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

Decreased periods of uterine relaxation between contractions

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

The client feels hopeless about the situation.

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?

Previous classical vertical uterine incision

A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the oxytocin induction?

Tell me what you mean when you say that your baby has moved."

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

To regain her breathing pattern

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care?

Maintain continuous electronic fetal monitoring

Fetal membranes are seen at the introitus Lengthening of umbilical cord Sudden trickle or spurt of blood

Which findings indicate to the nurse that placental separation has occurred? Select all that apply.