NCLEX

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?

Administering oxygen via face mask

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action is to monitor which criteria?

All vital signs, especially heart rate and blood pressure

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?

Anxiety related to a slow progress of labor

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?

Baseline fetal heart rate

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?

Check the fetal heart rate.

The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?

Decreased periods of uterine relaxation between contractions

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Determine the fetal heart rate.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Determine the parents' desires for contact with the newborn.

Which is the appropriate method to use to deliver the placenta after a precipitate delivery?

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?

Have the client empty her bladder.

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?

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?

Left lateral

The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which issue?

characteristics of contractions

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?

complete bedrest

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?

continue to monitor client

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?

decreasing BP

The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?

determine FHR

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?

lateral sims

The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?

newborn

The nurse should prepare to give a prescribed oxytocic medication after delivery of which?

placenta

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?

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

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.

-Bearing down with contractions -Changing body positions frequently -Making expiratory vocalizations

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.

-Bright red vaginal bleeding -Lack of uterine contractions

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.

-Change in uterine shape -Lengthening of the umbilical cord -Sudden gush of dark blood from the introitus

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.

-The fetus is in the breech position. -Lesions are present on the perineum. -The fetus is not settled into the pelvis.

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.

-The umbilical cord lengthens -Changes in the shape of the uterus -A trickle or gush of blood escapes from the introitus

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?

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

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.

-Bright red vaginal bleeding -Soft, relaxed, non-tender uterus -Fundal height may be greater than expected for gestational age

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?

Determine the maternal and fetal vital signs.

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?

Maintain continuous electronic fetal monitoring.

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?

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

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?

Prevent dehydration and hypoxemia.

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?

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

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?

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

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?

Supine with a wedge under the right hip

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?

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

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?

shoulder dystocia

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.

-Bright red vaginal bleeding -Soft, relaxed, nontender uterus

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.

-Constant fever of 101° F -Persistent pelvic heaviness -Foul-smelling vaginal discharge

A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply.

-Uterus soft to palpation -Bright red vaginal bleeding

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.

-board like abdomen -Increase in fundal height

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?

resting interval of 50 secs

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?

Document the findings and continue to monitor the fetal patterns.

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?

Supine position with a wedge under the right hip

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?

contraction stress test

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?

Prepare the client for a cesarean delivery.

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?

fear about what is happening

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?

The client feels hopeless about the situation.

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?

signs of shock

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?

Previous classical vertical uterine incision