Intrapartum Passpoint Prepu
A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective?
"Braxton hicks contractions begin in the abdomen and remain irregular"
The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's beststrategy in which to provide care in labor and birth when confronted with a cultural conflict?
"I will make every effort to work with your cultural beliefs."
The nurse admits a client in active labor at 38 weeks gestation. The client says to the nurse, "I was not expecting to go into labor so soon, so I did not have time to shave down there." How should the nurse respond?
"It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?"
The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider?
"My membrane ruptured 2 days ago"
A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion?
135 beats/minute
A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?
42 drops/minute.
The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN?
A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.
A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?
Ask the client about her most recent blood glucose levels.
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.
A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor?
Assist the client in performing effleurage.
A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate?
Cesarean delivery.
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in the fetal heart rate (FHR). After notifying the registered nurse in charge, what should the nurse do next?
Change the client's position.
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position.
A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take?
Contact the health care provider, supporting the client until an analgesic is prescribed.
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.
A 32-year-old 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. Which action taken by nurse promotes pain relief in the laboring client?
Direct pressure and massage to the sacral area.
The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications?
Encourage the client to practice breathing exercises to decrease the urge to push.
The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.
A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?
Fetal heart rate variability within an acceptable range
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?
Influence of the extended family.
Which intervention should be included in the safety plan for the maternal- infant unit?
Making sure that the spouse or significant other wears an identification band
A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next?
Massage the fundus
A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority?
Note the color, amount, and odor of the fluid.
A client with a high-risk pregnancy is admitted in the labor and delivery area. Internal fetal monitoring is to be initiated. Which action(s) should the nurse take before starting internal fetal monitoring? Select all that apply.
Prepare for manual rupture of the membrane. Check dilation of the cervix. Obtain baseline fetal heart rate and maternal vital signs. Explain the procedure to the client.
A client in labor requires an episiotomy. Which complication should the nurse have the client report to the health care provider after the procedure?
Prolonged dyspareunia.
A nurse is caring for a client in active labor who is crying and asking for something for pain. Her medical record shows that she does not tolerate prescribed opioid analgesics. Which of the following nonpharmacologic interventions might be helpful to this client?
Provide back massage to the client.
A primigravida client with severe gestational hypertension is admitted to the labor unit. She has been receiving magnesium sulfate IV for 3 hours. The latest data reveals deep tendon reflexes (DTRs) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and urine output of 20 mL/ hour. Which action would be most appropriate?
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?
Stop the visitor, and ask for identification.
A client in labor is receiving magnesium sulfate as an intravenous infusion. Which medication should the nurse ensure is at the bedside while the magnesium sulfate is being infused?
calcium gluconate
A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?
fetal heart rate of 80 beats/minute
During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by:
massaging and supporting the perineum
A client has given birth vaginally several minutes ago. The nurse notes blood gushing from the vagina, the umbilical cord lengthening, and a globe-shaped uterus. The nurse should monitor the client closely for which condition?
placental separation
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next?
prepare for immediate delivery of the baby.
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 bestdescribes why the nurse is asking questions about the family's birth plan?
recognizing the family as active participants in their care
A client is admitted to the labor unit in early labor. The nurse would encourage the client to assume which position to promote tissue perfusion?
side-lying
A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?
stimulates labor and prevents hemorrhage
A health care provider has ordered an IV of 5% dextrose in lactated Ringer's solution at 125 mL/hour. The IV tubing delivers 10 drops per mL. How many drops per minute should fall into the drip chamber?
20 to 21
Which of the following behaviors would 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.
The nurse is caring for a client who requested skin-to-skin contact with the newborn as part of the birth plan. The health care provider passes the newborn to another nurse who begins drying the newborn. What immediate action does the nurse take?
Ask that the other nurse stop drying the newborn and immediately place the newborn on the client's chest.
A nurse is caring for a client who has just delivered a neonate, and finds that the fundus is boggy and deviated to the right. Which action taken by the nurse helps with uterine involution?
Have the client void.
A client in the early stages of labor who is admitted to the labor and delivery unit is noted to have not recently bathed or changed her clothes. Which action should the nurse take to help this client?
Help the client to undress and suggest a quick bath to freshen up.
A client in labor has been given an epidural anesthetic. When collecting data on the client immediately following the epidural administration, which finding would be most important for the nurse to report?
Maternal blood pressure decreases from 130/70 to 98/50
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions?
Notify the obstetrician
A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action?
Notify the physician that the partner has been waiting to discuss the mother's condition.
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 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?
The national standards of practice were met when providing care.
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?
The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.
The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first?
What is your expected due date?
A client with hypotonic labor dysfunction has been prescribed oxytocin. When the nurse is providing care to the client, which findings would lead the nurse to suspect that the client may be experiencing water intoxication? Select all that apply.
headache vomiting dizziness
The nurse cares for a client on the labor and delivery unit who identifies as nonbinary and has asked to be referred to using nongendered pronouns. The nurse informs the unlicensed assistive personnel (UAP) who responds, "She's having a baby! Clearly, she's a female. This is ridiculous." How should the nurse respond? Select all that apply.
"Are you saying you will not use the client's requested gender-related language during the shift?" "Remember, you will address the client by their name when delivering care, so pronouns will not be used often." "Gender is different from biological sex designations. I can explain how to use an inclusive approach."
A client has received dinoprostone to help ripen her cervix. What should the nurse do to determine effectiveness of the drug?
Assess for ripening and softening of cervix.
Which care intervention is appropriate for the fourth stage of labor?
Assessing lochia and the location and consistency of the fundus
A client in the second stage of labor experiences membrane rupture. Which intervention by the nurse is appropriate?
Check for a prolapsed cord
A client who tested positive for the human immunodeficiency virus (HIV) is in active labor. During delivery, blood splashes and contaminates the care area. Which action should the nurse take?
Contact housekeeping and ask them to clean the area because it has been contaminated by blood-borne pathogens.
An actively laboring client who is 6 cm dilated and who attended natural childbirth classes asks the nurse for pain medication. What is the most appropriate action by the nurse?
Contact the health care provider for pain medication.
A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response?
Explain to the client that the feeling is normal during this stage.
