Maternal/Newborn Success NRS 245 Exam 1

A pregnant woman is discussing possible delivery options with a labor nurse. Which of the following client responses indicates that the woman understood the information? Select all that apply. a. "I am glad that deliveries can take place in a variety of places, including in the labor bed." b. "I heard that for a baby to be delivered safely, it is essential that I lie on my back with my legs up" c. "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." d. During difficult deliveries it is sometimes necessary to put a woman's legs in stirrups. e. "I heard that midwives often deliver their patients either in side laying or squatting position."

a. "I am glad that deliveries can take place in a variety of places, including in the labor bed." c. "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." d. During difficult deliveries it is sometimes necessary to put a woman's legs in stirrups. e. "I heard that midwives often deliver their patients either in side laying or squatting position."

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that client is at this time. a. 2 b. 4 c. 8 d. 10

a. 2

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply. a. Give the woman a back rub. b. Assist the woman with her breathing. c. Assess the fetal heart rate. d. Check the woman's BP. e. Regulate the woman's IV.

a. Give the woman a back rub. b. Assist the woman with her breathing.

The childbirth education nurse is evaluating the learning four women, 38-40 weeks gestation, regarding when they should go to the hospital. The nurse determines that the teaching was a success wen a client makes which of the following statements? a. If I feel a pain in my lower abdomen every 5 min. b. When I feel a gush of clear fluid prom my vagina. c. When I go to the bathroom and I see a mucous plug on the toilet paper. d. If I ever notice a greenish discharge form my vagina. e. When I ave felt cramping in my abdomen for 4 hours or more.

a. If I feel a pain in my lower abdomen every 5 min. b. When I feel a gush of clear fluid prom my vagina. d. If I ever notice a greenish discharge form my vagina.

The nurse auscultates a FHR of 152 bpm on a client in early labor. Which of the following actions by the nurse is appropriate? a. Inform the mother that the rate is normal. b. Reassess in 5 minutes to verify the results. c. Immediately report the rate to the HCP. d. Place the client on her left side and apply oxygen by face mask.

a. Inform the mother that the rate is normal.

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. a. Lengthening of the umbilical cord. b. FHR assessments after each contraction. c. Uterus rising in the abdomen and feeling globular. d. Rapid cervical dilation to 10 cm. e. Maternal complaints of rectal pressure.

a. Lengthening of the umbilical cord. c. Uterus rising in the abdomen and feeling globular.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short term and long term variability with a baseline FHR of 142 bpm. What should the nurse do? a. Provide caring labor support. b. Administer O2 via face mask. c. Change the clients position. d. Speed up the IV.

a. Provide caring labor support.

While evaluating the FHR tracing on a client in labor, the nurse notes that there are decelerations present. Which of the following assessments must the nurse make at this time? a. The relationship between the deceleration and the contraction. b. The maternal BP. c. The gestational age. d. The placement of the fetal heart electrode in relation to the fetal position.

a. The relationship between the deceleration and the contraction.

A nurse concludes that a woman is in latent phase of labor. Which of the following signs/symptoms that would lead a nurse to this conclusion? a. The woman talks and laughs during contractions. b. The woman complains about severe back pain. c. The woman performs effleurage during a contraction. d. The woman asks to go to the bathroom to defecate.

a. The woman talks and laughs during contractions.

The nurse is assessing an internal FHR monitor tracing of an unmedicated, full term gravida, who is in transition. Which of the following patterns would the nurse interpret as normal? a. Baseline of 140-150 with V-shaped decelerations to 120 unrelated to contractions. b. Baseline of 140-150 with decelerations to 100 that mirror each contraction. c. Baseline 140 - 142 with decelerations to 120 that return to the baseline after the end of the contraction. d. Baseline of 140-142 with no obvious decelerations or accelerations.

b. Baseline of 140-150 with decelerations to 100 that mirror each contraction.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? a. Awaken the woman and remind her to push. b. Cover the woman's perineum with a sheet. c. Assess the woman's BP and pulse. d. Administer O2 to the woman via face mask.

b. Cover the woman's perineum with a sheet.

A woman is in the second stage of labor and has the strong urge to push. Which of the following actions by the nurse is appropriate at this time? a. Assess the FHR between contractions every 60 sec. b. Encourage the woman to grunt during contractions. c. Assess the pulse and respirations of the mother every 5 minutes, d, Position the woman on her back with her knees to her chest.

b. Encourage the woman to grunt during contractions.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? a. Offer the client the bedpan b. Evaluate the progress of labor. c. Notify the physician. d. Encourage the patient to push

b. Evaluate the progress of labor.

The nurse is assessing a client that thinks they are in labor. Which of the following findings would positively confirm the clients belief? a. She is contracting every 5 minutes for 60 sec. b. Her cervix is dilated from 2-4cm. c. Her membrane has ruptured. d. The fetal head is engaged.

b. Her cervix is dilated from 2-4cm.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? a. Decreased pulse rate. b. Hypertension. c. Hyperthermia. d. Decreased respiratory rate.

b. Hypertension.

A woman is in the transition phase of labor. Which of the following comments should the nurses expect to hear? a. I am so excited to be in labor. b. I cant stand this pain any longer. c. I need ice chips because I am so hot. d. I have to push the baby out right now!

b. I cant stand this pain any longer.

In addition to breathing with contractions, what action will the nurse instruct a woman in labor to do during the first stage of labor? a. Lying in thee lithotomy position. b. Performing effleurage. c. Practicing Kegel exercises. d. Pushing with each contraction.

b. Performing effleurage.

A woman had a baby by normal spontaneous delivery ten minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? a. The woman has an internal laceration. b. The woman is about to deliver the placenta. c. The woman has an atonic uterus. d. The woman is ready to expel the cord bloods.

b. The woman is about to deliver the placenta.

A woman, G1P0000, 40 weeks gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2cm dilated, 30% effaced, contractions every 12 min. x 30 sec. FHR is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting thee findings to the primary HCP? a. The woman is at high risk and should be placed on tocolytics. b. The woman is in early labor and should be sent home. c. The woman is at high risk and should be induced. d. The woman is in active labor and should be admitted.

b. The woman is in early labor and should be sent home.

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage two. She states that her pain is a 6 out of 10 scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? a. "Epidurals do not work well when the pain is above a 5 on the scale." b. "I will contact the doctor to get an order for an epidural right away." c. "The baby is going to be born very soon. It is too late for an epidural." d. "I will check the FHR and you can have an epidural if it is over 120."

c. "The baby is going to be born very soon. It is too late for an epidural."

A primigravida is pushing with contractions. The nurse notes that the woman's perineum began to bulge and that there in an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? a. Report the findings to the clients HCP. b. Immediately assess the woman's pulse and BP. c. Continue to provide encouragement through each contraction. d. Place the client on her side with O2 via face mask.

c. Continue to provide encouragement through each contraction.

An OB is performing an amniotomy on a gravid woman in transition. Which of the following assessments should the nurse make immediately following the procedure? a. Maternal BP b. Maternal Pulse c. FHR d. Fetal Fibronectin level

c. FHR

A gravid client at term called the labor suite at 7pm questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: a. At 5pm my contractions were 5 minutes apart, now they are about 7" b. I took a walk at 5pm and now I can talk through my contractions easier. c. I took a shower half an hour ago. The contractions hurt more than they did before. d. I had some tightening in my belly late this afternoon, and I still feel it after waking up from a nap.

c. I took a shower half an hour ago. The contractions hurt more than they did before.

A client is complaining of severe back pain. Which of the following nursing interventions would be most effective? a. Assist the mother with child birth breathing. b. Encourage mother to have an epidural. c. Provide direct sacral pressure. d. Move the woman to a hydrotherapy tub.

c. Provide direct sacral pressure.

A nurse has performed a vaginal exam on a client in labor. The nurse palpates the baby's buttocks as facing the mothers right side. Where should the nurse place the external fetal monitoring electrode? a. LUQ b. LLQ c. RUQ d. RLQ

c. Right Upper Quadrant

A nurse describes a clients contraction pattern as: frequency 3 min. and duration of 60 sec. Which of the following responses corresponds to this description? a. Contractions lasting 60 seconds followed by a 1 minute rest period. b. Contractions lasting 120 seconds followed by a 2 minute rest period. c. Contractions lasting 2 minutes followed by 60 seconds of rest period. d. Contractions lasting 1 minute followed by a 120 second rest period.

d. Contractions lasting 1 minute followed by a 120 second rest period.

A women, G2P0101, 5CM Dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. the nurse detects that the woman's shoulder and face muscles are beginning to tense during thee contractions. Which of the following interventions should the nurse perform first? a. Encourage the woman to have an epidural. b. Encourage the woman to receive intravenous analgesics. c. Encourage the woman to change her position. d. Encourage the woman to perform the next level of breathing.

d. Encourage the woman to perform the next level of breathing.

The nurse documents in a laboring woman's chart that FHR is being "assessed via intermittent auscultation". To be consistent and this statement, the nurse, is using a Doppler electrode, should assess the FHR at which of the following times? a. After each contraction. b. For 10 minutes every half hour. c. Only during the peak of contractions. d. For 1 minute immediately after contractions.

d. For 1 minute immediately after contractions.

A low risk 38 weeks gestation woman calls the labor unit and say, " I have to come to the hospital right now, I just saw pick streaks in the toilet paper. Im bleeding." Which of the following responses should the nurse make first. a. do you feel burning when you void? b. You sound frightened. c. That is just your mucous plug. d. How much blood is there?

d. How much blood is there?

Upon examination, a nurse notes that a woman is 10 cm, dilated 100% effaced, and -3 station. Which of the following actions should the nurse perform during the next contraction? a. Encourage the woman to push. b. Provide firm fundal pressure. c. Move the client into a squat. d. Monitor for signs of rectal pressure.

d. Monitor for signs of rectal pressure.

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? a. Hold her breath for 20 seconds during each contraction. b. Blow out forcefully during each contraction. c. Push between contractions until the fetal head is visible. d. Take a slow cleansing breath before bearing down.

d. Take a slow cleansing breath before bearing down.

A woman, 40 weeks gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? a. The contractions are 5 to 20 minutes apart. b. I saw a pink discharge on the toilet paper when I went to the bathroom. c. I have had cramping the last three to four hours. d. The contractions are about a minute long and I am unable to talk through them.

d. The contractions are about a minute long and I am unable to talk through them.

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? a. alternately panting and blowing. b. rapid, deep breathing. c. grunting and pushing with contractions d. slow chest breathing

d. slow chest breathing