Intrapartum

The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first? Have the client push with a contraction. Ask the client to take a deep breath and hold it. Prepare an area to receive the neonate. Lower the head of the bed to a flat position.

Prepare an area to receive the neonate.

The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention? Administer IV oxytocin as prescribed. Apply an internal fetal scalp electrode. Instruct the client to push. Prepare for an emergency cesarean birth.

Prepare for an emergency cesarean birth.

A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client? Start an IV and give penicillin G every 4 hours until birth. Administer tocolytics as prescribed until the active lesions are healed. Administer valacyclovir 500 mg orally every 6 hours while in active labor. Prepare the client and partner for a cesarean birth as soon as possible.

Prepare the client and partner for a cesarean birth as soon as possible.

The nurse is preparing to assist the health care provider (HCP) with a cervical check for a client whose membranes have ruptured. What equipment should the nurse have ready for the HCP? Select all that apply. sterile speculum sterile gloves sterile lubricant amnio hook

sterile gloves sterile lubricant

A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? the client's partner the client's best friend, who's the sperm donor the client's parents, because they're blood relatives the court system, because the client isn't married and is legally responsible for the neonate

the client's partner

After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? "I'm going to have a higher blood pressure." "My membranes are likely to have a foul odor." "My contractions are going to be less painful." "I should try to push with each contraction."

"I should try to push with each contraction."

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan." "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." "I'll insert a urinary catheter; then you won't need to get out of bed."

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."

A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response? "This is a routine assessment and your baby is fine." "The baby has had a bowel movement, indicating severe fetal distress." "The baby needs to be observed more closely." "The baby has had a bowel movement, indicating mild fetal distress."

"The baby needs to be observed more closely."

Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently? Blood pressure decreases as a sign of maternal pain. Alterations in cardiovascular function affect the fetus. Blood pressure decreases at the peak of each contraction. Decreased blood pressure is the first sign of preeclampsia.

Alterations in cardiovascular function affect the fetus.

A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? Administer ephedrine to raise her blood pressure. Administer oxygen using a mask. Place the woman supine with her legs raised. Ensure adequate hydration before the anesthetic is administered.

Ensure adequate hydration before the anesthetic is administered.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Place the client in a Trendelenburg position. Administer oxytocin intravenously. Ask the client to begin pushing. Cover the cord with sterile towels.

Place the client in a Trendelenburg position.

The nurse is caring for a client who is attempting a trial of labor (attempt a vaginal birth after cesarean). Contractions are 1.5 minutes apart with a duration 75 to 90 seconds. The client reports a "sharp, tearing" pain, and the electronic fetal monitor (EFM) is no longer recording contractions. What is the priority nursing action? Perform a sterile vaginal exam (SVE). Prepare the client for an emergency cesarean birth. Insert an intrauterine pressure catheter. Reposition the client.

Prepare the client for an emergency cesarean birth.

The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention? The membranes are intact. The client has not received anesthesia. The cervix is fully dilated. The fetus is at 0 station.

The membranes are intact.

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? level of consciousness blood pressure cognitive function contraction pattern

blood pressure

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition? increased intensity of contractions fetal head engagement prolapsed cord a need for an analgesic medication

prolapsed cord

The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor? when the neonate has been born when the client is fully dilated and effaced when the placenta has been birthed when the client is 2 hours postpartum

when the placenta has been birthed

A pregnant client's labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which suggestion would be most helpful for the client's partner? "Keep a record of her contraction pattern." "Encourage her to rest between contractions." "Suggest that she receive an epidural anesthetic." "Have her practice rapid, shallow breathing."

"Encourage her to rest between contractions."

The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience what type of pain? no pain sharp pain light pain moderate pain

no pain

While waiting for the placenta to deliver, the nurse should not take any action before which action has occurred? asking the client to push down forcefully massaging the fundus firmly observing for signs of placental separation reaching into the uterus with sterile gloves

observing for signs of placental separation

The nurse is caring for a client in labor who has tested positive for gonorrhea. Which will the nurse include in the client's plan of care? Administer erythromycin eye drops to the infant after birth. Plan for a cesarean birth. Apply an internal fetal scalp electrode. Monitor the fetal heart tones every 4 hours.

Administer erythromycin eye drops to the infant after birth.

Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at −1 station. The client has indicated that she wants a "natural birth" with no analgesia or anesthesia. The health care provider (HCP) enters the room and tells the client that it is time for an epidural anesthetic. What would be the nurse's best action at this time? Ask the client if she desires an epidural anesthetic. Tell the HCP that the client desires a "natural birth." Tell the client that her labor will be more comfortable with an anesthetic. Ask the client to discuss this with her husband and then make a decision.

Ask the client if she desires an epidural anesthetic.

A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which intervention would the nurse do first? Check the status of the fetal heart rate. Turn the client to her right side. Test the leaking fluid with nitrazine paper. Perform a sterile vaginal examination.

Check the status of the fetal heart rate.

The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply. IV hydration maternal position change oxygen administration epidural pain medication increased oxytocin infusions

IV hydration maternal position change oxygen administration

The nurse is caring for a client in labor who is receiving epidural anesthesia. The nurse assesses a blood pressure of 80/40 mm Hg. Which of the following interventions will the nurse include in the client's plan of care? Turn off the client's epidural infusion. Increase the client's fluid rate. Monitor the fetal heart rate. Increase the epidural infusion rate.

Increase the client's fluid rate.

A multigravida in active labor is 7 cm dilated. The fetal heart rate 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? Perform a vaginal examination. Notify the health care provider (HCP) of the decelerations. Reposition the client and continue to evaluate the tracing. Administer oxygen via mask at 2 L/min.

Reposition the client and continue to evaluate the tracing.

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage? a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy a client who is a gravida 1 para 0 at 34 weeks gestation with mild pregnancy-induced hypertension a client who is a gravida 4 para 0 with diet-controlled gestational diabetes being induced at term a client who is a gravida 2 para 1 term pregnancy with a history of genital herpes

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy

A triage nurse is completing an initial assessment of several clients in the waiting room. Which client would the nurse see first? a client who reports passing "some thick, red-tinged mucus when I urinated this morning" a client who reports that her baby dropped lower into her pelvis, and who has to urinate more frequently a client with uterine contractions who reports "they are getting stronger and closer now" a client who is 12 days past her due date with cramping

a client with uterine contractions who reports "they are getting stronger and closer now"

During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that she smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate assessment, the nurse should monitor the client for symptoms of which complication? placenta previa ruptured uterus maternal hypotension abruptio placentae

abruptio placentae

At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate? risk for injury related to rapid delivery acute pain related to wearing off of anesthesia hyperthermia related to effects of anesthesia altered tissue perfusion related to effects of anesthesia

altered tissue perfusion related to effects of anesthesia

The nurse determines that a client has an antenatal or intrapartum risk score of 2. Based on this information, which activity level should the nurse recommend to the client during labor? bathroom privileges only ambulate as tolerated up in the chair at the side of the bed complete bed rest with IV hydration

ambulate as tolerated

The nurse is managing care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client? oxygen saturation monitoring every half hour supine positioning on back, if it is comfortable anesthesia/pain level assessment every 30 minutes vaginal bleeding, rupture of membrane assessment every shift

anesthesia/pain level assessment every 30 minutes

What actions does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply. assigning the Apgar scores administering oxytocin assisting with perineal repairs drying the newborn initiating skin to skin care taking newborn vital signs

assigning the Apgar scores drying the newborn initiating skin to skin care taking newborn vital signs

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? human resource director, so she can arrange vacation time for the staff physician, so he can provide education about HELLP syndrome social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff chaplain, because his educational background includes strategies for handling grief

chaplain, because his educational background includes strategies for handling grief

The nurse is assisting in the birthing room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate childbirth. Which interventions should the nurse perform when caring for the client after this procedure? Select all that apply. check the episiotomy repair site apply ice to the perineum change the dressings every shift administer pain medication, as prescribed explain perineal care to the client when she can focus on the instructions

check the episiotomy repair site apply ice to the perineum administer pain medication, as prescribed explain perineal care to the client when she can focus on the instructions

The nurse would question the prescription for a fetal scalp electrode on which client? client with an HIV infection client with late decelerations client with significant meconium stained fluid client with a prolonged second stage of labor

client with an HIV infection

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an IV infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? carefully titrating the oxytocin based on the client's pattern of labor monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes instructing the client to ambulate as tolerated helping the client use breathing exercises to manage her contractions

instructing the client to ambulate as tolerated

A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time? placing the client in bed to begin fetal monitoring preparing for immediate delivery checking for ruptured membranes providing comfort measures

preparing for immediate delivery

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern? spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds late decelerations that occur with over 50% of contractions repetitive (at least 3) uncomplicated variable decelerations late decelerations with minimal variability

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason? to prevent Rh-positive sensitization with the next pregnancy to provide active antibody protection for this pregnancy to decrease the amount of Rh-negative sensitization for the next pregnancy to destroy fetal Rh-positive cells during the next pregnancy

to decrease the amount of Rh-negative sensitization for the next pregnancy

A multigravid client who is 10 cm dilated is admitted to the labor and birth unit. In addition to supporting the client, what is the priority nursing action? turning on the infant warmer increasing IV fluids determining the client's preferences for pain control providing client education regarding care of the newborn

turning on the infant warmer

The nurse performs the initial assessment and reports the following findings to the health care professional: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage or phase of labor? second latent active third

active

A client has received epidural anesthesia to control pain during a vaginal birth. Place an X over the highest point on the body locating the level of anesthesia expected for a vaginal birth.

umbillicus

A nurse is caring for a client in labor. Which assessment finding indicates fetal distress? lack of meconium staining early decelerations in fetal heart rate during contractions an increase in fetal heart rate with fetal scalp stimulation fetal blood pH less than 7.2

fetal blood pH less than 7.2

The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's best response? "You cannot push yet, you have another 2 cm until you are ready." "Your cervix is not fully dilated. Let's keep breathing through the pressure." "Go ahead and push just a little when you feel the urge." "I will get you some IV pain medication to take the edge off."

"Your cervix is not fully dilated. Let's keep breathing through the pressure."

Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Do you have any chronic illnesses?" "Do you have any allergies?" "What is your expected due date?" "Who will be with you during labor?"

"What is your expected due date?"

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? checking for the umbilical cord around the neonate's neck placing antibiotic ointment in the neonate's eyes turning the neonate's head to the side to drain secretions assessing the neonate for respirations

checking for the umbilical cord around the neonate's neck

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? "I'm sorry, your provider will have to inform you of the results of the test." "The fetal heart rate dropped during the contractions, so we may need to induce you." "The fetal heart rate went up twice during the test, so your fetus is doing well." "It is too early to tell, we will need to repeat the test in 2 weeks."

"The fetal heart rate went up twice during the test, so your fetus is doing well."

A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor? fetal descent into the pelvic inlet cervical dilation and effacement painful contractions every 3 to 5 minutes leaking amniotic fluid clear in color

cervical dilation and effacement

A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at +1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which problem? cephalopelvic disproportion prolonged latent phase prolonged transitional phase hypotonic contraction pattern

cephalopelvic disproportion

A client in active labor is planning on epidural anesthesia for labor and birth. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when she makes which statement? "Sometimes the labor process is slower after the epidural anesthesia is administered." "If my bladder gets full, I may need to be catheterized." "I may not feel the urge to push with this type of anesthesia." "I may need to lie flat for 6 hours and drink plenty of fluids after I give birth."

"I may need to lie flat for 6 hours and drink plenty of fluids after I give birth."

A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin infusing. What is the nurse's best response? "I will get you a bedpan." "I will need to catheterize you." "I will get someone to help." "You can go to the bathroom whenever you need to."

"I will get someone to help."

The nurse instructs the client about the procedures that will be performed on the neonate immediately after birth to prevent meconium aspiration. The nurse determines that the instructions have been effective when the client states that which procedure will be done to her baby? "Suctioning will be needed if the baby is floppy." "A tube will be placed in the baby's nose." "The baby will be given oxygen by a mask." "The baby will be given a drug to dilate the bronchi."

"Suctioning will be needed if the baby is floppy."

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions? "Walking around helps to decrease true contractions." "True labor contractions may disappear with rest or sleep." "The duration and frequency of true labor contractions remain the same." "True labor contractions are felt first in the lower back, then the abdomen."

"True labor contractions are felt first in the lower back, then the abdomen."

A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: Give a 4-g bolus over 15 minutes, then decrease the rate to 2g/hour. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringer's on hand. What is the rate the nurse will set the pump to deliver the 2g maintenance dose? Record your answer using a whole number.

((2x1hr)x(1000x50)) = 40ml/hr

A client at 28 weeks' gestation in premature labor was placed on nifedipine. To maintain the pregnancy, the primary health care provider orders the client to have 20 mg now, followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 0600? Record your answer using military time.

2200

Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider? A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps. Using forceps will cause the neonate to develop a cephalohematoma and a vacuum extractor will not. Assisted vaginal births are very commonplace, especially in clients who have received epidurals. Clients having assisted vaginal births are less likely to experience a postpartum hemorrhage.

A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps.

A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which would be a priority intervention by the nurse to establish whether the client can have an epidural? Call a consult with anesthesia for an epidural. Measure the intensity of her contractions. Assess cervical dilation. Assess her response to intravenous morphine.

Assess cervical dilation.

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 nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. What should the nurse do first? Warm the temperature of the room by a few degrees. Increase the rate of intravenous fluid administration. Obtain an order for an intramuscular antiemetic medication. Assess the client's cervical dilation and station.

Assess the client's cervical dilation and station.

The health care provider (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, what should the nurse do first? Monitor the client's contraction pattern. Assess the fetal heart rate (FHR) for 1 full minute. Assess the client's temperature and pulse. Document the color of the amniotic fluid.

Assess the fetal heart rate (FHR) for 1 full minute.

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: X-linked recessive and the disease will only occur if the baby is a boy. X-linked dominant and there is no likelihood of the baby having cystic fibrosis. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.

A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. What activity should the nurse immediately perform? Administer oxygen via nasal cannula at 4 L/min. Change the client to the left lateral position. Inform the physician that birth is imminent. Begin continuous fetal heart rate monitoring.

Begin continuous fetal heart rate monitoring.

External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first? Notify the anesthesiologist. Change the client's position. Administer oxygen at 2 L by mask. Prepare the client for a cesarean birth.

Change the client's position.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? Tell the partner that to leave because the partner is intimidating the client. Question the woman in front of her partner. Contact hospital security to escort the partner from the hospital. Collaborate with the physician to make a referral to social services.

Collaborate with the physician to make a referral to social services.

A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which should be the nurse's next action? Administer prescribed antihypertensive medication. Increase the rate of IV oxytocin. Continue to monitor BP. Position the client on the side.

Continue to monitor BP.

The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do? Turn the client to her left side. Ask the client to push in the squatting position. Continue to monitor the client and fetus. Administer oxygen by mask at 8 L.

Continue to monitor the client and fetus.

A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug? The cervix will begin to dilate 2 cm/h. Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.

Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions.

A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take? Turn the client to her left side. Administer oxygen via facemask at 10 to 12 L/minute. Notify the health care provider (HCP) of the situation. Document fetal well-being.

Document fetal well-being.

A nurse is caring for a woman G1 P0 at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? Position the client on her left side, and administer O2 via face mask. Document findings on the client's chart, and continue to monitor labor progress. Perform vaginal exam to rule out umbilical cord prolapse. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean birth.

Document findings on the client's chart, and continue to monitor labor progress.

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? Position woman on her left side, and administer oxygen via face mask. Document findings on the woman's medical record, and continue to monitor labor progress. Perform vaginal exam to rule out umbilical cord prolapse. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean birth.

Document findings on the woman's medical record, and continue to monitor labor progress.

The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first? Ask the anesthesiologist to increase epidural rate. Assist the client to push if she feels the need to do so. Encourage the client to breathe through the urge to push. Support family members in providing comfort measures.

Encourage the client to breathe through the urge to push.

A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? The fetal scalp electrode is a small device that looks like a corkscrew. It's applied quickly after the baby's scalp is carefully palpated. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Inform the client that the fetal scalp electrode helps monitor fetal heart rate and assists with shortening the first stage of labor.

Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission.

Which nursing action is required before a client in labor receives an epidural anesthetic? Give a fluid bolus. Check for maternal pupil dilation. Assess maternal reflexes. Offer bedpan to void.

Give a fluid bolus.

The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent? Patterns of verbal communication Religious beliefs Influence of the extended family Gender identity

Influence of the extended family

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? Notify the physicians and explain that they need to teach their clients before inducing labor. Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Report the physicians for providing inferior care. Initiate a protocol order that allows the nurse to administer promethazine before administering oxytocin.

Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction.

A multiparous client at 33 weeks gestation is admitted to the labor and birth area with painless vaginal bleeding. Ultrasonography shows marginal placenta previa. Which nursing interventions should be included in the plan of care for this client? Select all that apply. Institute bed rest. Assess the cervix hourly. Establish intravenous (IV) access. Apply continuous fetal heart monitoring.

Institute bed rest. Establish intravenous (IV) access. Apply continuous fetal heart monitoring.

The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month-pregnant client performs what action? cardinal movements Leopold's maneuvers Friedman curve digital vaginal exam

Leopold's maneuvers

A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care? Monitor of intake and output. Insert an indwelling catheter. Restrict oral intake. Maintain bed rest.

Monitor of intake and output.

A primigravid client at 38 weeks' gestation comes to the labor room because "my water broke." The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. What action should the nurse take next? Notify the HCP that the membranes are ruptured. Perform a sterile vaginal examination to assess the cervix. Document the findings of the nitrazine test. Offer the client a sterile sanitary pad after performing perineal care.

Notify the HCP that the membranes are ruptured.

An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count 10,000/μl (10 x 109/L), hemoglobin 14.5 g/dL (145 mmol/L), and hematocrit 40% (0.40). The Venereal Disease Research Laboratory (VDRL) test is positive. The nurse notifies the health care provider of the laboratory results. Which is the priority intervention by the nurse? Notify the laboratory that a repeat hemoglobin and hematocrit have been prescribed. Recommend that the client drink plenty of fluids. Notify the Neonatal Intensive Care Unit of the client's status. Ask the client if she has been exposed to varicella in the past 3 weeks.

Notify the Neonatal Intensive Care Unit of the client's status.

While the client is in active labor with twins and the cervix is 5-cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. What should the nurse do next? Note the fetal heart rate patterns. Notify the health care provider immediately. Administer oxygen at 6 L by mask. Have the client pant/blow during the contractions.

Notify the health care provider immediately.

A client who has abruptio placentae exhibits cyanosis in the earlobes, capillary filling time >3 seconds, and reports "heartburn." Which is the best nursing intervention? Notify the healthcare provider immediately. Assess for vaginal bleeding. Increase the temperature of the room and provide warmed blankets. Elevate the head of the bed.

Notify the healthcare provider immediately.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse's the priority action? Reassure the patient and assist with nonpharmacologic pain interventions. Assess the intensity of contractions and determine if she would like an epidural. Notify the provider of the pain and request an assessment for potential abruption. Perform a vaginal examination and coach the woman with breathing exercises for pain control.

Notify the provider of the pain and request an assessment for potential abruption.

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 vaginal exam 1 hour 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? Help the client through contractions until a narcotic can be given. Palpate the bladder to see if it has become distended. Ask the client for suggestions to make her more comfortable. Perform a vaginal examination to determine if the client is fully dilated.

Perform a vaginal examination to determine if the client is fully dilated.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? Place the mother in a knee-to-chest position. Palpate the cord for pulsations before notifying the physician. Attempt an external cephalic rotation. Restore circulation by stimulating the cord with a sterile glove.

Place the mother in a knee-to-chest position.

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions? Position to left lateral, O2 per nonrebreather mask at 10 L. Position to knee-chest, increase IV fluids. Give orange juice, vibroacoustic stimulation. Administer terbutaline, turn off oxytocin infusion.

Position to left lateral, O2 per nonrebreather mask at 10 L.

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, the nurse should perform which action next? Tell the client to push between contractions. Provide gentle support to the fetal head. Apply gentle upward traction on the neonate's anterior shoulder. Massage the perineum to stretch the perineal tissues.

Provide gentle support to the fetal head.

Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next? Assess the client's pulse rate. Decrease the rate of intravenous fluids. Provide the client with a warm blanket. Assess the amount of blood loss.

Provide the client with a warm blanket.

Assessment of a primigravida in active labor reveals cervical dilation at 9 cm with complete effacement and the fetus at +1 station. What should the nurse do when the primary care provider prescribes meperidine 50 mg intramuscular (IM) for the client? Administer the medication in the left ventrogluteal muscle. Be certain that naloxone is at the client's bedside. Ask the primary care provider to validate the dosage of the drug. Refuse to administer the medication to the client.

Refuse to administer the medication to the client.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor? Breathe slowly after each contraction. Avoid the use of analgesics for the labor pain. Remain in a side-lying position with the head elevated. Request local anesthesia for vaginal birth.

Remain in a side-lying position with the head elevated.

A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful? Stand silently at the back of the room. Stand next to her at the side of the bed. Turn up the volume of the music playing in the room. Turn on the television as a focal point.

Stand next to her at the side of the bed.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next? Continue monitoring per standards of care. Stop the magnesium sulfate infusion. Increase the infusion rate by 5 gtt/minute. Decrease the infusion rate by 5 gtt/minute.

Stop the magnesium sulfate infusion.

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol? Call security personnel to remove the visitor. Check to make sure each neonate is with its parent. Stop the visitor, and ask for identification. Note the time and a detailed description of the individual.

Stop the visitor, and ask for identification.

The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate which other client finding within the next week? The client will develop preeclampsia. The fetus will develop mature lungs. The client will not develop preterm labor. The fetus will not develop gestational diabetes.

The client will not develop preterm labor.

A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse should contact the health care provider (HCP) for clarification in what circumstance? The client's membranes have ruptured. The client's pregnancy is multifetal. The client has been diagnosed with type 2 diabetes. The client is exhibiting hypotonic labor patterns.

The client's membranes have ruptured.

After being in labor for 12 hours, a primigravid client is now 10 cm dilated, and the presenting part is at 0 station. The nurse should inform the client and family members that what is occurring? The first stage of labor is beginning. The client is now in the active phase. Birth will occur in the next few minutes. The second stage of labor is now beginning.

The second stage of labor is now beginning.

A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? The time of membrane rupture The frequency of contractions The presence of fetal movement after the membranes ruptured The color of the ruptured fluid

The time of membrane rupture

Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is >20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first? Notify the health care provider (HCP). Turn off the oxytocin infusion. Turn the client to her left side. Increase the maintenance IV fluids.

Turn off the oxytocin infusion.

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene? 60-79 beats per minute 80-120 beats per minute 121-160 beats per minute 161-200 beats per minute

Turn the client to her side.

A gravida 3 para 1 laboring client is 9 cm dilated and is changing position frequently to cope with the intensity of the contractions. The client's partner has gone to the cafeteria to take a break. The client tells the nurse that she is tired but is afraid of being left alone and that her partner will miss the birth. Which of the following is the nurse's most appropriate action? Tell the client that someone will try to find her partner. Return to the nurse's station to phone the health care provider because birth is imminent. Tell the client not to worry because the birth likely won't happen for another 4-5 hours. Use the call bell to ask another nurse for help locating the client's partner.

Use the call bell to ask another nurse for help locating the client's partner.

A registered nurse is delegating the monitoring of a client who is receiving oxytocin to induce labor to a new graduate nurse. When discussing adverse side effects of oxytocin, which conditions would the graduate nurse notify the registered nurse of immediately? Select all that apply. a blood pressure of 170/92 mm Hg jaundice in the sclera lab work suggesting dehydration fluid overload with crackles in the lung fields palpable uterine tetany a heart rate of 60 beats/minute

a blood pressure of 170/92 mm Hg fluid overload with crackles in the lung fields palpable uterine tetany

After teaching a woman who is in labor about the purpose of the episiotomy, which purpose stated by the client would indicate to the nurse that the teaching was effective? assists with birth of a large baby enlarges the pelvic inlet prevents perineal edema ensures quick placental delivery

assists with birth of a large baby

Which client is the best candidate for a vaginal birth after a caesarean (VBAC)? client who had an emergency caesarean birth because of fetal distress during her last birth and has a classic incision client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy client who dilated 6 cm in her last delivery and failed to progress beyond this point despite 5 more hours of labor diabetic client whose last infant was over 10 lb (4.5 kg). This infant is larger, as seen on ultrasound.

client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy

The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action? closed glottis pushing open glottis pushing "rest and descent" squatting while pushing

closed glottis pushing

A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred? abruptio placentae prolapsed cord partial placenta previa complete uterine rupture

complete uterine rupture

A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client? client preference complexity of care requirements continuity: the nurse who cared for the client yesterday the most senior nurse on that morning shift

complexity of care requirements

A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. What should the nurse assess first after admission to the birthing area? time of last food and fluid intake fetal position and station contraction frequency and intensity ability to follow directions

contraction frequency and intensity

The nurse has administered meperidine to a client in labor. Which change in the fetal heart rate tracing would the nurse expect to occur as a result of the meperidine administration? decreased fetal heart rate variability fetal bradycardia repetitive late decelerations early decelerations

decreased fetal heart rate variability

The end of the third stage of labor is marked by what event? the birth of the neonate complete dilation delivery of the placenta transfer of the client to the postpartum bed

delivery of the placenta

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? prolonged decelerations early decelerations late decelerations accelerations

early decelerations

A client in labor asks the nurse about Reiki, an alternative therapy that she's heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of vigorous massage. energy from light touch. energy from a light source. mind-body control.

energy from light touch.

A 30-year-old multigravida pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when she says that an electronic monitor performs which function? allows fetal assessment after the administration of analgesia ensures a more comfortable atmosphere for the client and labor provides a continuous recording of fetal heart rate allows the nurse to monitor both fetuses simultaneously

ensures a more comfortable atmosphere for the client and labor

The health care provider (HCP) prescribes intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which interval? every 15 minutes during the latent phase every 30 minutes during the active phase every 60 minutes during the pushing phase every 2 hours during the transition phase

every 30 minutes during the active phase

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? an episode of nausea after administration of an epidural anesthetic contractions 3 minutes apart and lasting 40 seconds evidence of spontaneous rupture of the membranes sleeping after administration of IV nalbuphine

evidence of spontaneous rupture of the membranes

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia? abnormally long uterine contractions abnormally strong uterine contractions excessively frequent contractions, with rapid fetal movement excessive fetal activity and fetal tachycardia

excessive fetal activity and fetal tachycardia

For the past 8 hours, 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 moderate variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for which problem? exhaustion. chills and fever. fluid overload. meconium-stained fluid.

exhaustion.

The nurse cares for a multigravid client in active labor with a fetus in a frank breech presentation. The nurse should notify the primary care provider if the nurse makes which observation? fetal bradycardia at any time during the labor process intense uterine contractions during the transition phase of labor maternal tachycardia during a contraction meconium-stained amniotic fluid during the second stage of labor

fetal bradycardia at any time during the labor process

A client whose cervix is 10 cm dilated begins to push. The nurse notes early decelerations of the fetal heart rate. The nurse should interpret this finding as being caused by which factor? cord compression fetal bradycardia fetal head compression inadequate uteroplacental perfusion

fetal head compression

In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia variable decelerations fetal heart rate accelerations late decelerations

fetal heart rate accelerations

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion? fetal heart rate variability within 5 to 10 beats/minute persistent fetal bradycardia late decelerations variable decelerations and sinusoidal pattern

fetal heart rate variability within 5 to 10 beats/minute

A 32-year-old primigravida at 39 weeks' gestation is admitted to the hospital in active labor. While the nurse performs Leopold's maneuvers, the client asks why these maneuvers are being done. The nurse explains that the major purpose of these maneuvers is to determine which factor? fetal presentation fetal size estimated gestational age intensity of contractions

fetal presentation

A client is admitted in early active labor at 39 weeks' gestation with intact membranes. When assessing the fetal heart rate, the nurse locates the heart sounds above the client's umbilicus at midline. The nurse should further confirm that the fetus is lying in which position? cephalic frank breech face transverse

frank breech

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief? lithotomy right lateral hands and knees tailor sitting

hands and knees

The nurse is caring for a client during the fourth stage of labor. Which complications is the nurse most alert for at this time? Select all that apply. arrhythmias hemorrhage dizziness mastitis urinary retention

hemorrhage dizziness urinary retention

A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for which condition? spinal headache hypotension hyperreflexia uterine relaxation

hypotension

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client? ineffective denial related to a socially unacceptable infection impaired parenting related to the neonate's transfer to the intensive care unit deficient fluid volume related to severe edema fear related to removal and loss of the neonate by statute

impaired parenting related to the neonate's transfer to the intensive care unit

A client isn't progressing with dilation during labor. Her physician recommends a cesarean birth to minimize the potential for fetal distress. After surgery, what should the nurse assess for in this client? Select all that apply. infection hemorrhage hematuria mastitis endometritis

infection hemorrhage hematuria

Which conditions are contraindications to epidural blocks? Select all that apply. infection at the injection site allergy to the anesthetic drug urinary tract infection anticoagulant therapy bleeding disorder

infection at the injection site allergy to the anesthetic drug anticoagulant therapy bleeding disorder

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe? intravenous penicillin intravenous gentamicin sulfate intramuscular betamethasone intramuscular cefaclor

intravenous penicillin

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? active phase latent phase expulsive phase transitional phase

latent phase latent = dilation 3-4, abd cramps, back pain active = dilation 5-7, contractions every 2-5 minutes transitional = dialtion 8-10, contractions every1.5-2 minutes

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use? deep kneading of superficial muscles secure grasping of muscular tissues light stroking of the skin surface prolonged pressure on specific sites

light stroking of the skin surface

A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The health care provider prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she 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 naloxone local anesthetic pudendal block

naloxone

When the nurse is preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? oxytocin infusion solution disposable tongue blades portable ultrasound machine padding for the side rails

padding for the side rails

A primigravid client at about 36 weeks' gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which person must the nurse notify? nursing unit manager so appropriate agencies can be notified head of the hospital's security department chaplain in case the fetus dies in utero primary care provider who will attend the birth of the infant

primary care provider who will attend the birth of the infant

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking gingko biloba to help manage her blood sugars. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication? medication interactions hypertensive crisis oversedation prolonged bleeding

prolonged bleeding

A nurse is caring for a 28-week gestation primigravida client in the labor and birth area. The client reports that she has not felt fetal movement in more than 3 days. Ultrasonography reveals intrauterine fetal demise. Which laboratory finding is indicatives of a potentially serious complication? prolonged prothrombin time (PT) negative D-dimer decreased red blood cell (RBC) count increased white blood cell (WBC) count

prolonged prothrombin time (PT)

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan? establishing rapport with the family acting as an advocate for the family attempting to correct any misinformation the family may have received recognizing the family as active participants in their care

recognizing the family as active participants in their care

Which statement describes the term fetal position? relationship of the fetus's presenting part to the mother's pelvis fetal posture fetal head or breech at cervical os relationship of the fetal long axis to the mother's long axis

relationship of the fetus's presenting part to the mother's pelvis

The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which position? lithotomy side-lying hands and knees prone

side-lying

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity? the moderate amount of bloody show the frequency of the uterine contractions the intact membranes the position of the baby

the intact membranes

Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client feels a strong need to have a bowel movement. What is the client most likely experiencing? a precipitous labor pattern fear and anxiety related to the labor outcome spontaneous rupture of the membranes the second stage of labor

the second stage of labor

A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor? active phase latent phase expulsive phase transitional phase

transitional phase

The nurse is caring for a client with abruptio placenta. What signs and symptoms of abruptio placenta would be expected when collecting data on this client? Select all that apply. vaginal bleeding decreased fundal height uterine tenderness on palpation soft abdomen on palpation hypotonic, small uterus abnormal fetal heart tones

vaginal bleeding uterine tenderness on palpation abnormal fetal heart tones

Which fetal presentation is most favorable for birth? vertex presentation transverse lie frank breech presentation posterior position of the fetal head

vertex presentation

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

The neonate will be born with mature lungs.

A client in active labor asks the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse? "It is part of our standard policy." "Changes in your blood pressure can affect the fetus." "Low blood pressure may cause dizziness and fainting." "Increased blood pressure is a sign of preeclampsia."

"Changes in your blood pressure can affect the fetus."

The nurse assesses the perineal changes of a woman in the second stage of labor. The figure below represents which perineal change? anterior-posterior slit oval opening circular shape crowning

crowning

What data indicates to the nurse that placental detachment is occurring? an abrupt lengthening of the cord a decrease in the number of contractions relaxation of the uterus decreased vaginal bleeding

an abrupt lengthening of the cord

The nurse has administered promethazine intravenously to a client in active labor. The drug has had the desired effect when the nurse notes which finding? decreased nausea and vomiting increased fetal heart rate increased contraction strength increased blood pressure in the client

decreased nausea and vomiting

A pregnant client's partner coaches her with breathing and relaxation techniques as they were taught in birth preparation classes. When the client reaches 8-cm dilation, she screams out, "I can't do this anymore!" Which suggestion would be most helpful for the client's partner? "Let me take over the coaching for a while." "Ask your partner if she wants anesthesia." "Tell your partner that it will be over soon." "Maintain direct eye contact and breathe with her."

"Maintain direct eye contact and breathe with her."

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to the physician on call. the social worker on call. Women in Distress (local provincial/territorial, regional or aboriginal shelter). a lawyer.

the social worker on call.

A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section? physician admitting nurse the nurse assigned to the client senior staff nurse

physician

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? use of protective goggles during a caesarean birth placement of bloody sheets in a container designated for contaminated linens wearing of sterile gloves to bathe a neonate at 2 hours of age disposal of used scalpel blades in a puncture-resistant container

wearing of sterile gloves to bathe a neonate at 2 hours of age

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? Have naloxone hydrochloride available in the birthing room. Complete a vaginal examination. Prepare for birth. Document the client's relief due to pain medication.

Complete a vaginal examination.

The nurse is teaching a G2P1 client about her upcoming labor. Which response would indicate to the nurse that further teaching is necessary? "I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long." "Braxton Hicks contractions may stop if I walk or drink water." "I may have blood-tinged mucus when my cervix begins to efface." "I should contact my doctor if I experience a sudden gush of vaginal fluid."

"I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long."

A client had a cesarean section with her first pregnancy and is hoping to have a vaginal birth with this pregnancy. She begins to cry at her 38-week visit when she realizes that her baby is a breech presentation. She says, "I just know it's going to be horrible again. I won't be able to breastfeed my baby. It will be painful." What response from the nurse is appropriate? "Tell me about your previous baby's birth." "Don't worry. We will be here to help you through this." "A cesarean section is always done for breech presentation." "It is safer to have a cesarean section than a vaginal birth after cesarean."

"Tell me about your previous baby's birth."

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

"The anesthetic may cause a severe headache, which is treatable."

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response? "Yes, but only after you read about the procedure in the regional policy and procedure manual." "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." "Yes, but I will demonstrate it once and then supervise you while you perform the procedure." "No, only certified registered nurses can perform this skill."

"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

The nurse is caring for a couple in the transition period of labor. The client's partner asks about helping with the client's comfort at this time. What is the nurse's best response? "There's nothing that you can do to help right now." "You can stay close and help her focus on her breathing." "Please hold her leg back while she pushes." "You can go to the cafeteria to get her something to eat."

"You can stay close and help her focus on her breathing."

After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which event occurs? The uterus becomes oval shaped. The uterus enlarges. A sudden gush of dark blood appears. The client expends efforts pushing.

A sudden gush of dark blood appears.

The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She is too upset by what is happening to make this decision." What should the nurse do? Ask the client if this is acceptable to her. Have the client and her husband both sign the consent form. Ask the client to sign the consent form. Ask the HCP to witness the consent form.

Ask the client to sign the consent form.

The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first? Administer oxygen by mask at 4 L. Change the client's position. Contact the client's primary care provider. Document the tracing in the client's record.

Change the client's position.

The primary care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction? Administer a 500 mL bolus of intravenous fluid to prevent hypotension. Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes. Insert an indwelling urinary catheter to determine intake and output accurately. Call the anesthesiologist to begin administration of epidural anesthesia.

Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? Contractions will be stronger and more uncomfortable and will peak more abruptly. Contractions will be weaker, longer, and more effective. Contractions will be stronger, shorter, and less uncomfortable. Contractions will be stronger and shorter and will peak more slowly.

Contractions will be stronger and more uncomfortable and will peak more abruptly.

A 19-year-old primigravid client at 38 weeks' gestation 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? Use the McDonald procedure to widen the pelvic opening. Increase the rate of oxygen and intravenous fluids. Instruct the client to use a pant-blow pattern of breathing. Tell the client to push only when absolutely necessary.

Instruct the client to use a pant-blow pattern of breathing.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time? Teach the client progressive muscle relaxation. Instruct the partner on touch, massage, and breathing patterns. Use hypnosis on the client and her partner. Teach the client and her partner about pain transmission.

Instruct the partner on touch, massage, and breathing patterns.

A woman who gave birth to her last infant by caesarean birth is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo "a trial labor." What does the nurse explain to the client that trial of labor means? Labor will be stimulated with exogenous oxytocin until delivery. The HCP needs more information to determine the presence of true labor. Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Labor will be arrested with tocolytic agents after a 2-hr period even if no fetal distress is noted.

Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery.

Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate? Have the client take several whiffs of oxygen through a nasal cannula. Give the client a paper bag and have her breathe into it. Tell the client to breathe quickly and then hold her breath. Encourage the client to inhale with as much force as possible.

Give the client a paper bag and have her breathe into it.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? Be in a semi-Fowler's position or a position of comfort Flex the thighs onto the abdomen before bearing down. Exert downward pressure as if having a bowel movement. Hold the breath throughout the length of the contraction.

Hold the breath throughout the length of the contraction.

A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? Complete an initial assessment on a client. Increase the oxytocin rate on a laboring client. Perform a straight catheterization for protein analysis. Assess a laboring client for a change in labor pattern.

Perform a straight catheterization for protein analysis.

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse? Prepare for birth, reposition the patient, and begin pushing. Perform sterile vaginal examination, increase IV fluids, and apply oxygen. Notify the provider, explain findings to the client, and begin pushing. Reposition the client, apply oxygen, and increase IV fluids.

Reposition the client, apply oxygen, and increase IV fluids.

A client at 28 weeks' gestation is admitted in preterm labor. An IV infusion loading dose of 4 g magnesium sulfate is started IV piggyback at a rate of 300 mL/min. After 15 minutes, the nurse assesses the client's deep tendon reflexes and finds them hyporeflexive. What is the nurse's priority intervention? Give calcium gluconate IV push. Call the health care provider. Check the client's blood pressure. Stop the magnesium sulfate infusion.

Stop the magnesium sulfate infusion.

A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), what should the nurse do? Decrease the IV fluid rate. Turn the client to her side. Catheterize the client. Perform a vaginal examination.

Turn the client to her side.

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? an increased sense of rectal pressure a decrease in intensity of contractions an increase in fetal heart rate variability episodes of nausea and vomiting

an increased sense of rectal pressure

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine inversion. atony. involution. discomfort.

atony.

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse? total weight gain of 30 lb (13.6 kg) maternal age of 32 years blood pressure of 146/90 mm Hg treatment for syphilis at 15 weeks' gestation

blood pressure of 146/90 mm Hg

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation? breech position transverse lie occiput posterior position compound presentation

breech position

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? duration, frequency, and intensity dilation, duration, and frequency frequency, duration, maternal position dilation, effacement, position

duration, frequency, and intensity

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor? maternal fatigue fetal malposition small-for-gestational-age fetus effects of analgesic medication

effects of analgesic medication

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness

fetal heart rate

The health care provider (HCP) orders an amniocentesis for a primigravid client at 37 weeks' gestation to determine fetal lung maturity. Which is an indicator of fetal lung maturity? amount of bilirubin present presence of red blood cells Barr body determination lecithin-sphingomyelin (L/S ratio)

lecithin-sphingomyelin (L/S ratio)

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? excitement loss of control numbness of the legs feelings of relief

loss of control

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority? massaging the uterus assessing vital signs assisting client to empty her bladder assisting client to left lateral position

massaging the uterus

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? fetal tachycardia maternal hypotension maternal tachycardia maternal oliguria

maternal hypotension

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to prevent seizures. reduce blood pressure. slow the process of labor. increase diuresis.

prevent seizures.

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 for the client to assume? dorsal recumbent lithotomy hands and knees squatting

squatting

A nurse is assisting in the birthing room. The healthcare provider prepares to perform a midline episiotomy. On the illustration, identify the area where the healthcare provider makes the incision.

perineum, between anus and vagina

A nurse recognizes that labor is divided into how many stages? two three four five

three (early, active, transition)

A laboring client at 28 weeks gestation is in preterm labor. Her partner gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse? "Your partner seems to be coping just fine. She has managed very well today." "You and your partner have been through a lot with this pregnancy. Let's talk about this further." "You seem really stressed. Do you have any one to talk to about this?" "I know you are upset. However you need to put this in perspective for the sake of your partner and infant."

"You and your partner have been through a lot with this pregnancy. Let's talk about this further."

A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 ml normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using a whole number.

((500/20)x20) = 50

An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. Honor the mother's request. Knowing the client's cultural background, suggest that the family call a meeting to make the decision. Request that an anesthetist administer the epidural because the client is uncomfortable.

Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time? Encourage client to drink the ice and water. Offer the client hot beverages. Increase the IV oxytocin to 125 mL/hr for hydration. Ask the client what fluids she prefers to drink.

Ask the client what fluids she prefers to drink.

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first? Increase the rate of the oxytocin infusion. Turn the client to a knee-to-chest position. Assess cervical dilation and effacement. Assess the fetal heart rate.

Assess the fetal heart rate.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission? Review the client's obstetrical history. Assess the client's coping skills in labor. Ensure that the client will have a support person in labor. Assess the imminence of birth.

Assess the imminence of birth.

The nurse hears a pregnant client yell, "Oh my! The baby is coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is being born. What should the nurse do first? Suction the mouth with two fingertips. Check for presence of a cord around the neck. Tell the client to bear down with force. Advise the mother that help is on the way.

Check for presence of a cord around the neck.

The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed? Perform a nonstress test. Perform a sterile vaginal exam. Check the fetal heart rate for bradycardia. Prepare for an imminent birth.

Check the fetal heart rate for bradycardia.

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply. Increase the oxytocin infusion. Contact the healthcare provider. Administer oxygen to the client. Discontinue the external fetal heart monitor. Change the client's position.

Contact the healthcare provider. Administer oxygen to the client. Change the client's position.

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? Perform a vaginal examination to determine dilation. Auscultate the client's blood pressure. Note the color, amount, and odor of the amniotic fluid. Prepare the client for imminent birth.

Note the color, amount, and odor of the amniotic fluid.

A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action? Encourage the partner to take a break for 1 hour. Instruct the partner to contact another support person take their place because the partner is exhausted. Offer to remain with the client while the partner takes a short break. Suggest that the partner goes home to sleep for a few hours.

Offer to remain with the client while the partner takes a short break.

The nurse is caring for a pregnant client. The nurse notes hypotension and a non-reassuring fetal heart tracing. Which action would the nurse include in the client's plan of care? Position the client on her left side. Have the client empty her bladder. Encourage the client to hold her breath. Call the health care provider.

Position the client on her left side.

The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention? Initiate oxytocin infusion. Call anesthesia to give epidural anesthesia. Prepare for birth of the neonate. Assess for rupture of the membranes.

Prepare for birth of the neonate.

During labor, a low-risk multigravid client in active labor has begun pushing, and the fetal head is beginning to crown. What action should the nurse take to prevent perineal lacerations during the birth? Stretch the perineal tissues with sterile gloved fingers. Hold the fetal head back with a sterile gloved hand. Tell her to stop pushing during the next two contractions. Ask her to hold her breath while pushing during the entire contraction.

Stretch the perineal tissues with sterile gloved fingers.

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

The cord lengthens outside the vagina.

The client and her partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence? Actions were based on the advice of a more experienced nurse. The nurse holds competencies required for nursing care. The national standards of practice were met when providing care. The healthcare provider's (HCP's) written orders were followed.

The national standards of practice were met when providing care.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply. Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client. Discuss the case with the client's mother, who is an immediate family member. Discuss the case at lunch to educate other staff members. Keep a unit log of all clients infected with HIV for research purposes.

Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client.

A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which problem? conjunctivitis heart disease harlequin sign brain damage

conjunctivitis

During the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints? headache, blurred vision, and facial and extremity swelling abdominal pain, urinary frequency, and pedal edema diaphoresis, nystagmus, and dizziness lethargy, chest pain, and shortness of breath

headache, blurred vision, and facial and extremity swelling

A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time? increased maternal blood pressure of 150/90 mm Hg decreased amount of vaginal bleeding fetal heart rate of 80 beats/minute maternal heart rate of 65 beats/minute

fetal heart rate of 80 beats/minute

The health care provider (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? assessment of the fetal hematocrit level increase in the strength of the contractions increase in the fetal heart rate and variability assessment of fetal position

increase in the fetal heart rate and variability

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care? offering support by reviewing the short-pant form of breathing administering opioid analgesia encouraging the mother to receive epidural anesthesia watching for rupture of the membranes

offering support by reviewing the short-pant form of breathing

A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? oxytocin 30 units in 500 ml D5W prostaglandin gel 0.5 mg misoprostol 50 mcg dinoprostone 10 mg

oxytocin 30 units in 500 ml D5W

The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? passage of meconium by the fetus maternal intrauterine infection Rh incompatibility between mother and fetus maternal sexually transmitted disease

passage of meconium by the fetus

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 client's severe back pain is most likely caused by the fetal occiput being in which position? breech transverse posterior anterior

posterior

When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal system? urinary gastrointestinal cardiovascular pulmonary

pulmonary

The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. What is the nurse's priority intervention? repositioning the client to the other side administering a fluid bolus administering oxygen at 10L per non-rebreather mask notifying the healthcare provider

repositioning the client to the other side

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem? congenital anomalies pulmonary hypertension meconium aspiration syndrome respiratory distress syndrome

respiratory distress syndrome

A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement? time of fetal scalp electrode placement, name of the HCP who placed the electrode, and frequency of uterine contractions time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR) the name of the HCP who applied the electrode, Doppler transducer placement, and FHR the maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR

time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR)

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? head chest umbilical cord placenta

umbilical cord

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? insufficient perineal stretching rapid, progressive labor umbilical cord prolapse fetal prematurity

umbilical cord prolapse