Intrapartum

A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which findings indicate a need to contact the registered nurse (RN)? Select all that apply. 1.Hemoglobin of 11 g/dL 2.Blood pressure reading of 144/94 3.Fetal heart rate of 180 beats per minute 4.Maternal pulse rate of 85 beats per minute 5.White blood cell count of 12,000 mm3

2, 3

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? Select all that apply. 1.Rigid, boardlike abdomen 2.Bright red vaginal bleeding 3.Lack of uterine contractions 4.Pain rating of 6 on a scale of 1 to 10 5.Fetal heart rate below 100 beats per minute

2, 3

Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal? Select all that apply. 1.It is dark amber in color. 2.Amniotic fluid pH is basic. 3.It is light green with no odor. 4.It is thick and white with a musky odor. 5.It is pale, straw-colored with flecks of vernix. 6.A volume of 1000 mL is an acceptable amount of amniotic fluid.

2, 5, 6

The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond? 1.Document the findings. 2.Transport the client to the delivery room. 3.Increase the rate of an oxytocin infusion. 4.Administer oxygen via face mask to the mother.

Administer oxygen via face mask to the mother.

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem? 1.Anxiety and fear 2.Feeling powerless 3.Lack of parenting skills 4.Lack of sensory perception

Anxiety and fear

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1.Baseline fetal heart rate 2.Intensity of contractions 3.Maternal blood pressure 4.Frequency of contractions

Baseline fetal heart rate

The nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing which condition? 1.Abruptio placentae 2.Incompetent cervix 3.Marginal placenta previa 4.Complete placenta previa

Complete placenta previa

The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note? 1.Latent phase of 2 hours 2.Descent of 1 cm per hour 3.Decreased periods of uterine relaxation between contractions 4.Dilation of the cervix of 2 to 4 cm per hour during the active phase

Decreased periods of uterine relaxation between contractions

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1.Determine the fetal heart rate. 2.Prepare for immediate delivery. 3.Monitor the contraction pattern. 4.Note the amount, color, and odor of the amniotic fluid.

Determine the fetal heart rate

The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action? 1.Provide peripads to the client. 2.Determine the fetal heart rate. 3.Take the client's blood pressure. 4.Note the amount, color, and odor of the amniotic fluid.

Determine the fetal heart rate.

The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted? 1.Fetal tachycardia 2.Increased urinary output 3.Contractions occurring every 3 minutes 4.Soft uterine tone palpated between contractions

Fetal tachycardia

Which is the appropriate method to use to deliver the placenta after a precipitate delivery? 1.Wait for approximately 30 minutes and then pull it out. 2.Wrap the cord around a sponge stick and tug upward. 3.Gently guide the placenta out after a spontaneous separation. 4.The nurse's scope of practice does not include delivering the placenta.

Gently guide the placenta out after a spontaneous separation.

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed? 1.Locate fetal heart tones. 2.Warm the sonogram gel. 3.Have the client empty her bladder. 4.Have the client drink 8 ounces of water.

Have the client empty her bladder

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside? 1.Code cart 2.Suction machine 3.Nasogastric tube 4.Intravenous (IV) supplies

Intravenous (IV) supplies

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1.Prepare for an oxytocin infusion. 2.Keep the client in a side-lying position. 3.Prepare the client for epidural anesthesia. 4.Encourage the client to start pushing with the contractions.

Keep the client in a side-lying position.

A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position? 1.Prone 2.Left lateral 3.High-Fowler's 4.Supine on the back

Left lateral

A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. In addition to maintaining complete bed rest, which other actions should the nurse include in the plan of care? 1.Encourage fluids and reduce stimuli. 2.Monitor IV fluid intake and monitor the fetal heart rate. 3.Assist with the vaginal exam and restrict food and fluids. 4.Monitor IV fluid intake and monitor for uterine contractions.

Monitor IV fluid intake and monitor the fetal heart rate.

The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? 1.Monitoring fetal status 2.Providing comfort measures 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor

Monitor fetal status

The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which action at this time? 1.Change the woman to a side-lying position. 2.Administer oxygen at 8 to 10 L/min by face mask. 3.Notify the registered nurse of a possible prolapsed cord. 4.Notify the registered nurse of a possible maternal infection.

Notify the registered nurse of a possible maternal infection.

The nurse should prepare to give a prescribed oxytocic medication after delivery of which? 1.Placenta 2.Infant's body 3.Infant's head 4.Infant's shoulders

Placenta

A client was admitted to the maternity unit 12 hours ago at station 0 and has been experiencing strong contractions every 3 minutes, and the fetus is currently still at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate? 1.Prepare to induce labor. 2.Turn the client to the left side. 3.Prepare the client for a cesarean delivery. 4.Continue to monitor the fetal heart rate pattern.

Prepare the client for a cesarean delivery.

The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, which nursing action can the nurse implement that will promote the birth of the placenta? 1.Increasing the IV infusion rate 2.Keeping the client in the lithotomy position 3.Adding oxytocin to the intravenous (IV) infusion 4.Putting the baby to the mother's breast and letting the baby suck

Putting the baby to the mother's breast and letting the baby suck

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client? 1.The client lacks self-esteem from being ill. 2.The client feels hopeless about the situation. 3.The client is grieving because of her condition. 4.The client lacks knowledge about the disease process.

The client feels hopeless about the situation

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding? 1.Soft abdomen on palpation 2.Uterine tenderness on palpation 3.No complaints of abdominal pain 4.Lack of uterine irritability or tetanic contractions

Uterine tenderness on palpation

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which? 1.1 inch below the coccyx 2.1 inch below the iliac crest 3.1 cm above the ischial spines 4.1 fingerbreadth below the symphysis pubis

1 cm above the ischial spines

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply. 1."Leopold's maneuvers are used to determine fetal position." 2."Leopold's maneuvers are used to determine actual fetal heart rate." 3."Leopold's maneuvers are used to determine duration of contractions." 4."Leopold's maneuvers are used to determine frequency of contractions." 5."Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6."Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."

1, 5, 6

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern? 1.105 beats per minute, minimal variability 2.150 beats per minute, moderate variability 3.170 beats per minute, absent variability 4.180 beats per minute, mild variability

150 beats per minute, moderate variability

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action is to monitor which criteria? 1.Effacement and dilation of the cervix 2.Frequency, duration, and intensity of contractions 3.The presence of both clear and red vaginal discharge 4.All vital signs, especially heart rate and blood pressure

All vital signs, especially heart rate and blood pressure

The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which issue? 1.Presence of edema 2.Signs of hyperglycemia 3.Presence of vaginal bleeding 4.Characteristics of contractions

Characteristics of contractions

The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia? 1.Leopold's maneuver 2.McRoberts' maneuver 3.Placing the client in the lithotomy position 4.Positioning the client laterally on her left side

McRoberts' maneuver

The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery? 1.Mother 2.Newborn 3.Support person 4.Primary health care provider

Newborn

A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure? 1.A stress test 2.A cesarean birth 3.Internal uterine contraction monitoring 4.Frequent repositioning from the right to the left side

A cesarean birth

During the intrapartum period, the nurse is caring for a laboring client diagnosed with sickle cell disease. The nurse recognizes that which conditions are most likely to lead to a sickling crisis? Select all that apply. 1.Exertion 2.Infection 3.Hypoxemia 4.Dehydration 5.Analgesic administration

1, 2, 3, 4

The nurse is evaluating the effectiveness of meperidine hydrochloride for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief? 1.Contractions are longer, stronger, and closer together. 2.Pain level is "5" with increased amounts of bloody show. 3.Pain level is "4" while a progressive labor pattern continues. 4.Pain level is "0" and the client experiences a period of rest from labor contractions.

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

Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta? 1.Wait 5 minutes for placental separation and then pull on the cord. 2.Pull gently on the cord following placental separation as the mother bears down. 3.Place traction on the cord and pull on the placenta as it enters the vaginal canal. 4.Encourage placental separation using forceps, and allow the placenta to deliver spontaneously.

Pull gently on the cord following placental separation as the mother bears down.

If a precipitate delivery is imminent, which is the appropriate nursing action? 1.Immediately contact the primary health care provider, and call for assistance. 2.Put on sterile gloves, and gently guide the baby's head and shoulders out. 3.Place the client in the Trendelenburg's position, and apply oxygen to the mother. 4.Medicate the mother, and delay the delivery until the primary health care provider arrives.

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

The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose? 1.Assist the baby in engaging into the birth canal. 2.Achieve an accurate measurement of urinary output. 3.Reduce the risk of injuring the bladder during the surgery. 4.Help prevent the possibility of developing a bladder infection.

Reduce the risk of injuring the bladder during the surgery.

A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority? 1.Continue to time the contractions. 2.Determine the need for education. 3.Give acetaminophen (Tylenol) for the temperature. 4.Report the time of last food intake to the primary health care provider.

Report the time of last food intake to the primary health care provider.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse? 1.Deep tendon reflexes of 2+ 2.Respirations of 10 breaths per minute 3.Fetal heart tones of 116 beats per minute 4.Urinary output of 20 mL since the last check

Respirations of 10 breaths per minute

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time? 1.Change in position 2.Oral food and fluids 3.Intravenous analgesia 4.Rest between contractions

Rest between contractions

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock? 1.Cold and clammy skin 2.Decreased blood pressure 3.Restlessness and agitation 4.Diminished peripheral pulses

Restlessness and agitation

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1.The maneuvers measure the height of the maternal fundus. 2.The maneuvers determine the "lie" and "attitude" of the fetus. 3.The maneuvers are a systematic method for palpating the fetus through the maternal back. 4.The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

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

The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply. 1.Ease of administration 2.Absence of fetal hypoxia 3.Immediate onset of anesthesia 4.Blockade of sympathetic fibers 5.Increased voluntary expulsive efforts 6.Decreased incidence of bladder atony

1, 2, 3

A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action? 1.Check the fetal heart rate. 2.Monitor the contraction pattern. 3.Prepare the client for immediate delivery. 4.Note the amount, color, and odor of the amniotic fluid.

Check the fetal heart rate.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? 1.Estimate the fetal size. 2.Check pelvic adequacy. 3.Administer an analgesic. 4.Determine the maternal and fetal vital signs.

Determine the maternal and fetal vital signs.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which? 1.Encourage immediate breastfeeding. 2.Complete routine newborn care measures quickly. 3.Determine the parents' desires for contact with the newborn. 4.Suggest the mother hold the newborn after the placenta is delivered.

Determine the parents' desires for contact with the newborn.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action? 1.Notify the registered nurse. 2.Administer oxygen via face mask. 3.Place the mother in Trendelenburg's position. 4.Document the findings and continue to monitor the fetal patterns.

Document the findings and continue to monitor the fetal patterns.

The nurse is monitoring the status of a client in active labor. The nurse interprets that which findings are consistent with dystocia? Select all that apply. 1.Signs of fetal distress 2.High level of maternal anxiety 3.Failure of the fetus to descend 4.Leaking of a clear liquid from the vagina 5.Progressive but slow changes in the cervix

1, 2, 3

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position? 1.Lithotomy 2.Knee-chest 3.Lateral Sims' 4.Semi-recumbent

Lateral Sims'

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1.Lengthening of umbilical cord 2.Sudden trickle or spurt of blood 3.Fundus is boggy following separation 4.Change from globular to discoid shape 5.Fetal membranes are seen at the introitus

1, 2, 5

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitudes? Select all that apply. 1.Alertness 2.Irritability 3.Excitement 4.Seriousness 5.Helplessness

1, 3

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply. 1.Encourage frequent urination. 2.Maintain absolutely nothing by mouth (NPO). 3.Continue maternal and fetal assessments. 4.Review breathing and relaxation techniques. 5.Provide a bed bath because the client cannot shower.

1, 3, 4

For the previous 4 hours, a client in labor has been experiencing hypertonic labor as documented by the primary health care provider. The nurse recognizes which findings to be characteristic of this type of labor? Select all that apply. 1.Contractions typically occur in the latent phase of labor. 2.Contractions occurring every 8 minutes, lasting 40 seconds. 3.Contractions occurring every 2 minutes, lasting 70 seconds. 4.Hypertonic uterine dysfunction is most likely to occur in the multigravida. 5.Contraction force is felt in the midsection of the uterus rather than the fundus.

1, 3, 5

When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply. 1.One vein 2.Two veins 3.One artery 4.Two arteries 5.One capillary 6.Two capillaries

1, 4

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor? 1.Reassure the client. 2.Maintain strict asepsis. 3.Prevent bearing-down. 4.Administer oxygen as prescribed.

Administer oxygen as prescribed.

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action? 1.Administering oxygen via face mask 2.Placing the mother in a supine position 3.Increasing the rate of the intravenous (IV) oxytocin infusion 4.Documenting the findings and continuing to monitor the fetal patterns

Administering oxygen via face mask

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care? 1.Anxiety related to a slow progress of labor 2.Anxiety related to previous parenting issues 3.Anxiety related to the inability to achieve relaxation 4.Anxiety related to physical and emotional maternal exhaustion

Anxiety related to a slow progress of labor

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage? 1.Effleurage is the application of pressure to the sacrum to relieve a backache. 2.Effleurage is light stroking of the abdomen to facilitate relaxation during labor. 3.Effleurage is a form of biofeedback to enhance bearing-down efforts during delivery. 4.Effleurage is a contracting of a specific muscle group while other parts of the body rest.

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

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety? 1.Emphasize the technical aspects of this type of delivery. 2.Decide how soon the client should see the baby after delivery. 3.Decrease the partner's anxiety by keeping him or her in the waiting area. 4.Encourage the client to discuss her concerns and desires regarding anesthesia options.

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

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time? 1.Inability to cope 2.Deficient sensory perception 3.Fear about what is happening 4.Lack of control over the situation

Fear about what is happening

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response? 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver

Fear of losing control

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect? 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased blood pressure (BP) monitoring

Increased efficiency of contractions

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care? 1.Administer antibiotics. 2.Maintain complete bed rest. 3.Notify the neonatal resuscitation team. 4.Maintain continuous electronic fetal monitoring.

Maintain continuous electronic fetal monitoring.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? 1.Leopold's maneuvers 2.A manual pelvic examination 3.Hemoglobin and hematocrit evaluation 4.External electronic fetal heart rate monitoring

Manual pelvic exam

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip? 1.Age of client 2.Maternal vital signs 3.Last menstrual period 4.A temporary interruption in recording

Maternal vital signs

The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines? 1.Longitudinal lie 2.Minus (-) 1 station 3.Vertex presentation 4.Right occiput anterior (ROA) position

Minus (-) 1 station

The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action? 1.Administer oxygen. 2.Monitor the fetal heart rate. 3.Notify the registered nurse immediately. 4.Place the client in the Trendelenburg's position.

Monitor the fetal heart rate.

The nurse is assigned to care for a client experiencing dystocia. Which is the highest priority in planning care? 1.Comfort measures, change of position, and touch 2.Explanations to family members about what is happening in this situation 3.Reinforcement of breathing techniques learned in childbirth preparatory classes 4.Monitoring for changes in the physical and emotional condition of the mother and fetus

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

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate? 1.Notify the registered nurse (RN). 2.Continue monitoring the fetal heart rate. 3.Encourage the client to continue pushing with each contraction. 4.Encourage the client's coach to continue encouraging breathing techniques.

Notify the registered nurse (RN).

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication? 1.High platelet count 2.Oozing from injection sites 3.A reddened rash over the trunk 4.Pain and swelling of the calf of one leg

Oozing from injection sites

At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 11:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action? 1.Palpate the bladder for fullness. 2.Turn the client on her right side. 3.Prepare the client for a cesarean delivery. 4.Prepare the client for the induction of labor.

Prepare the client for a cesarean delivery.

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted? 1.Presence of accelerations 2.Evidence of fetal bradycardia 3.Presence of late decelerations 4.Decreased fetal heart rate variability

Presence of accelerations

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal? 1.Stimulate the labor process. 2.Prevent dehydration and hypoxemia. 3.Avoid the necessity of a cesarean delivery. 4.Eliminate the need for analgesic administration.

Prevent dehydration and hypoxemia.

A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the oxytocin induction? 1.L/S ratio 2:1 2.Gestational diabetes 3.Hemoglobin level of 11.6 g/dL 4.Previous classical vertical uterine incision

Previous classical vertical uterine incision

The nurse is assigned to assist in caring for a client in labor. The nurse determines that which sign/symptom would least likely indicate dystocia? 1.Signs of fetal distress 2.Failure of a fetus to descend 3.Progressive changes in the cervix 4.High level of maternal fear or anxiety

Progressive changes in the cervix

The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Monitor the oxytocin infusion closely. 4.Promote ambulation every 30 minutes.

Provide pain relief measures.

The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication? 1.Resting interval of 50 seconds 2.Contraction duration of 75 seconds 3.Fetal heart tones of 154 beats/minute 4.Fetal variable decelerations lasting 60 seconds

Resting interval of 50 seconds

The nurse caring for a client who is receiving oxytocin for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which is the nurse's priority action? 1.Stop the oxytocin infusion. 2.Check the client's blood pressure. 3.Check the client for bladder distention. 4.Place the client in a knee-chest position.

Stop the oxytocin infusion.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1.Prone position 2.Semi-Fowler's position 3.Trendelenburg's position 4.Supine position with a wedge under the right hip

Supine position with a wedge under the right hip

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position? 1.Trendelenburg's with the legs in stirrups 2.Supine with a wedge under the right hip 3.Prone with the legs separated and elevated 4.Semi-Fowler's with a pillow under the knees

Supine with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1.Support the mother in her reaction to the newborn. 2.Encourage the mother to breastfeed soon after birth. 3.Tell the mother that it is important to hold the newborn. 4.Document a complete account of the mother's reaction in the birth record.

Support the mother in her reaction to the newborn.

The nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC? 1.Prolonged clotting times 2.Decreased platelet count 3.Swelling of the calf of one leg 4.Petechiae, oozing from injection sites, and hematuria

Swelling of the calf of one leg

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse? 1."Tell me what you mean when you say that your baby has moved." 2."The primary health care provider is all set to go and cannot change plans now." 3."That would be impossible because babies don't move around this late." 4."You need to listen to your primary health care provider; he knows what he is doing."

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

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure? 1."I'm getting tired of lying flat on my back." 2."I shut the machine off when I talk on the telephone." 3."What an efficient way to record my baby's heart rate." 4."How many volts of electricity are going through my body?"

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

During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which rationale should the nurse provide to the client for these interventions? 1."Adequate IV fluids and oxygen will stimulate and accelerate the labor process." 2."Administering IV fluids and oxygen will reduce the need for analgesic administration." 3."Providing adequate IV fluids and oxygen during the labor process will minimize the necessity of a cesarean delivery." 4."Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling."

"Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling."

The nurse is caring for a client in labor. The nurse reviews the primary health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. Which client statement indicates that the client understands the purpose of receiving this medication? 1."I should experience at least some pain relief shortly after receiving this medication." 2."My labor contraction pattern will become much stronger after I take this medication." 3."My labor contraction pattern will decrease some allowing for more rest time between contractions." 4."Taking this medication will allow my baby's lungs to mature In order to prevent respiratory problems following birth."

"I should experience at least some pain relief shortly after receiving this medication."

The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement? 1."I'm having bloody show." 2."The contractions are intense." 3."My cervix is completely dilated." 4."My membranes are now ruptured."

"My cervix is completely dilated."

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which signs as an indication of placental separation? Select all that apply. 1.Sudden abdominal pain 2.Change in uterine shape 3.Shortened umbilical cord 4.Lengthening of the umbilical cord 5.Decreased blood flow from the introitus 6.Sudden gush of dark blood from the introitus

2, 4, 6

A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply. 1.Low back pain 2.Uterus soft to palpation 3.Dark red vaginal bleeding 4.Frequent brief contractions 5.Bright red vaginal bleeding

2, 5

The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply. 1.The membranes are ruptured. 2.The fetus is in the breech position. 3.Lesions are present on the perineum. 4.The fetus is not settled into the pelvis. 5.The pregnancy is at 41 weeks' gestation.

2, 3, 4

A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort? 1.Turn the client to the lateral position. 2.Assist the client to ambulate in the room. 3.Allow the client to sit on the side of the bed. 4.Place a pillow under one hip when lying in the supine position.

Assist the client to ambulate in the room.

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture? 1.Primigravidity 2.Shoulder dystocia 3.Hypotonic contractions 4.Weak bearing-down efforts

Shoulder dystocia

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1.Squatting 2.Side-lying 3.Tailor sitting 4.Semi-Fowler's

Side-lying

The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which sign or symptom? 1.Leg pain 2.Signs of shock 3.Abdominal pain 4.Red vaginal discharge

Signs of shock

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what? 1.General anesthesia 2.To be left totally alone 3.To push with her contractions 4.To regain her breathing pattern

To regain her breathing pattern

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority? 1.Has a urinary catheter been inserted? 2.Was the informed consent form signed? 3.When was the last time the client ate or drank? 4.Is there a current complete blood cell count result in the client's medical record?

When was the last time the client ate or drank?

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery? 1.Hemoglobin of 11.5 g/dL 2.Fetal heart rate of 154 beats per minute 3.Maternal pulse rate of 90 beats per minute 4.White blood cell count of 35,000 mm3

White blood cell count of 35,000 mm3

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure? 1.Pelvic exam 2.Amniocentesis 3.Contraction stress test 4.Chorionic villus sampling

Contraction stress test

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse should suspect the client is how far dilated? 1.1 to 2 cm 2.3 to 4 cm 3.5 to 7 cm 4.8 to 10 cm

8 to 10 cm

The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply. 1.A soft and boggy uterus 2.The umbilical cord lengthens 3.Changes in the shape of the uterus 4.Maternal complaints of severe uterine cramping 5.A trickle or gush of blood escapes from the introitus

2, 3, 5

A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply. 1.Nausea 2.Boardlike abdomen 3.Heavy vaginal mucus 4.Increase in fundal height 5.Early deceleration on the monitor

2, 4

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply. 1.Fundus nonpalpable 2.Constant fever of 101° F 3.Persistence of lochia alba 4.Persistent pelvic heaviness 5.Foul-smelling vaginal discharge

2, 4, 5

The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply. 1.Following directions readily 2.Talking about labor experience 3.Bearing down with contractions 4.Making expiratory vocalizations 5.Changing body positions frequently

3, 4, 5

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus

4, 5

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

4, 5, 6

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1.A change in the uterine contour 2.Sudden and sharp abdominal pain 3.A shortening of the umbilical cord 4.A decrease in blood loss from the introitus

A change in the uterine contour

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client? 1.Up in chair 2.Ambulation 3.Complete bed rest 4.Bathroom privileges

Complete bed rest

The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time? 1.Report the fetal heart rate immediately. 2.Prepare for imminent delivery of the fetus. 3.Report the contractions because they reflect a potential complication. 4.Continue monitoring the client because the data reflect acceptable progress.

Continue monitoring the client because the data reflect acceptable progress.

The client is in the second stage of labor. As the baby begins to crown, the primary health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take? 1.Assess the client's blood pressure and fetal heart rate more frequently now. 2.Monitor more closely for fetal heart rate decelerations and loss of variability. 3.Assess the client's pulse and respirations every 2 minutes for the next 20 minutes. 4.Continue to assess vital signs and fetal heart rate the same as before the nerve block.

Continue to assess vital signs and fetal heart rate the same as before the nerve block.

The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action? 1.Prepare for delivery. 2.Continue to monitor the client. 3.Report the FHR to the registered nurse. 4.Notify the registered nurse immediately about the progress of labor.

Continue to monitor the client.

The nurse is caring for the nullipara woman in labor. The nurse understands that the primary health care provider must be contacted if which condition becomes apparent? 1.Descent of less than 1 to 2 cm/hr 2.Latent phase of less than 6 hours 3.Decreased periods of uterine relaxation between contractions 4.Dilation of the cervix of greater than 1 and less than 5 cm/hr during the active phase

Decreased periods of uterine relaxation between contractions

A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding is noted if complete rupture occurs? 1.Maternal bradycardia 2.Decreasing blood pressure 3.Excessive vaginal bleeding 4.Increased uterine contractions

Decreasing blood pressure