Nclex Intrapartum 40
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?
Administer oxygen via face mask to the mother
The nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
Changes in the shape of the uterus
The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take?
Continue to assist vital signs and fetal heart rate the same as before the nerve block
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 fetal patterns
the advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply.
Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia
The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?
Effleurage is light stroking of the abdomen to facilitate relaxation during labor.
Which would be the appropriate method to use to deliver the placenta after a precipitate delivery?
Gently Guide the placenta out after 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
For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes lasting 60 to 70 seconds and strong to palpation. She is dilated 2 cm and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?
Hypertonic
A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position?
Left lateral
The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?
McRobert's maneuver
The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
Minus (-) 1 station
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?
Monitoring 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?
Notify the registered nurse of a possible maternal infection.
A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently 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?
Prepare the client for a cesarean delivery.
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.
The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
Home History Help Calculator Review ModeQuestion 15 of 100 Previous 15 ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse caring for a client who is receiving oxytocin (Pitocin) 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?
STOP THE OXYTOSIN INFUSION
The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse would place the client at risk for uterine rupture?
Shoulder dystocia
The nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.
Signs of fetal distress 2. High level of maternal anxiety 3. Failure of the fetus to descend
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?
Support the mother in her reaction to the newborn.
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 preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?
When was the last time the client ate or drank?
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?
empty her bladder
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 patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?
Administering oxygen via face mask
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?
Assist the client to ambulate the room
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
A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?
Determine the parent's desire for contact with the newborn
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?
Fetal Tachycardia
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?
Restlessness and agitation
ENGLISH
answer
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 relax nontender uterus
Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?
Change In Uterine Shape
A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?
Encourage the client to discuss her concerns and desires regarding anesthesia options.
The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?
Monitor the fetal heart rate.
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 perform
Have the client empty her bladder
