NCLEX maternity L&D

the nurse in the labor room is caring for a client in the active stage of the first phase of labor. the nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. what is the most appropriate nursing action.

Administer oxygen via face mask

The nurse is caring for a client in labor. which assessment finding indicates to the nurse that the client is begining the second stage of labor?

The cervix is dilated completely.

the nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the clients abdomen. after attachment of the electric fetal monitor, what is the next nursing action?

assess the baseline of the fetal heart rate.

the nurse is ccaring for a client in labor and is monitoring the fetal heart rate patterns. the nurse notes the presence of episodic accelerations on the electrionic fetal monitor tracing. which action is most appropriate?

docuement the findings and tell the mother that the pattern on the monitor represents fetal well-being.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. which assessment finding would indicate the need to contact the hcp?

fetal heart rate of 180 bpm.

a client arrives at a birthing center in active labor. her membranes are still intact, and the hcp prepares to perform an amniotom. what will the nurse relay to the client was the most likely outcomes of the amniotomy?

increased efficiency of contractions.

the nurse is monitoring a client in active labor and notes that the client is having contracctions every 3 minutes that last 45 seconds. the nurse notes that the fetal heart rate between contractions is 100 bmps. which nursing action is most appropriate?

notify the hcp.

a client in labor is transported to the delivery room and prepared for a cesarean delivery. after the client is transferred to the delivery room table, the nurse should put the client in what position?

supine position with a wedge under the right hip.

the nurse is monitoring a client in labor. the nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

variable decelerations.

the nurse has provided discharged instructions to a client who delivered a healthy newborn by cesarean delivery. which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

the nurse is reviewing the record of a client in the labor room and notes that the hcp has documented that the fetal presenting part is at the -1 station. this documented finding indicates that the fetal presenting part is located at which area?

1 cm above the ischial spine