L&D

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?

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

A nurse recognizes that labor is divided into how many stages?

4 Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum.

The third stage of labor ends

after delivery of the placenta

A primary care provider has prescribed nalbuphine hydrochloride 10 mg intravenously for a client in active labor. The pharmacy supplies a vial labeled as 50 mg in a 5-mL vial. How many milliliters should the nurse administer? Record your answer using a whole number.

1

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?

Continue to monitor the client and fetus.

What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia?

offering encouragement and support

A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem?

pain

A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor and possible vaginal birth. After several hours of active labor, the primary care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which stateme

the contractions dont seem as painful as before

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?

Hold the breath throughout the length of the contraction.

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.

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?

duration, frequency, and intensity

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?

early decelerations

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?

evidence of spontaneous rupture of the membranes

A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?

Initiate fetal and contraction monitoring.

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?

preparing for immediate delivery

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 memebrane rupture

The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client makes which statement?

"I can have an epidural as soon as I start contracting."

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

increase sense of rectal pressure

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?

loss of control

A nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan?

Fear related to a potentially difficult childbirth

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 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

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?

left lateral

A nurse needs to obtain a good monitor tracing on a client in labor The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first?

Reposition the client to her left side.

What assessment data of a laboring woman would require further intervention by the nurse?

maternal heart rate 125 beats/minute All data are normal except for the maternal heart rate of 125 beats/minute. Normal maternal heart rate is 60-100 beats/minute. The elevated heart rate is a possible signal of developing complications.

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?

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

A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply.

Walk in the hospital room. Use slow chest breathing. Lightly massage the abdomen.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

check fetal heart rate

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?

push with each contraction

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 recognize that the client is in which phase of labor?

transitional phase

Which fetal presentation is most favorable for birth?

vertex position

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?

"Maintain direct eye contact and breathe with her."

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?

Place the client in a Trendelenburg position.

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?

anesthesia/pain level assessment every 30 minutes

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?

complete SVE

Which statement describes the term fetal position?

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

When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if

the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

beginning of one contraction to the beginning of the next contraction

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?

fetal heart rate accelerations

A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply.

interpretation of the fetal monitor strip analgesia or anesthesia being used prior birth history amount of vaginal bleeding or discharge support persons with the client

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?

the second stage of labor

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?

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

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

A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client?

Assess maternal contraction and fetal heart rate pattern.

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?

cervical dilation and effacement

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?

change pt position

The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time?

walking in the hallway

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?

what is your exspected due date

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?

posterior

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?

prolasped cord

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?

umbilical cord

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?

excessive fetal activity and fetal tachycardia

When assessing the fetal heart rate tracing, a nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve:

fetal hypoxia

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?

hypotention

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

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?

latent phase