OB exam 2: chapters 8-11 prep U's

second stage

A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor? a. first stage b. second stage c. third stage d. fourth stage

Initial intravenous fluid therapy

A patient who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the patient's fluid status during the procedure? a. Provide with a clear liquid tray. b. Encourage intake with ice chips. c. Initial intravenous fluid therapy. d. Administer an antiemetic as prescribed

infection

A woman is about to go for her first cesarean delivery and asks the nurse what complications can come from this type of delivery. The nurse correctly identifies which of the following as the number one complication of cesarean delivery? a. Laceration of the uterus b. Hemorrhage c. Laceration of the bladder d. Infection

-2

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? a. +4 b. +2 c. 0 d. -2

turning inward to concentrate on body sensations

During the second stage of labor, a woman is generally: a. very aware of activities immediately around her. b. anxious to have people around her. c. no longer in need of a support person. d. turning inward to concentrate on body sensations

Cervix

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? a. False pelvis b. Cervix c. Perineum d. Uterus

Significant head molding

Which physical characteristic of the neonate is typically present in the neonate of a primigravida mother? a. Thick vernix b. Single palmar crease c. Significant head molding d. Absence of testicular rugae

naloxonenaloxone

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? a. butorphanol b. fentanyl c. naloxone d. promethazine

Dinoprostone vaginal insert

A client presents at 41 weeks gestation for induction of labor and an attempt at VBAC. The nurse is aware that which method would be contraindicated for this client? a. Oxytocin b. Artificial rupture of membranes c. Balloon catheter insertion d. Dinoprostone vaginal insert

blue

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: a. yellow b. olive green c. pink d. blue

Prepare for an emergency cesarean delivery

A 24-year-old primigravida has been laboring longer than 24 hours. She has entered the second stage of labor, and the baby is at +2 station. The fetal heart rate has been 90 bpm for the last 2 minutes. The physician applies a Kiwi vacuum; after 3 attempts (pop-offs), the baby is not delivered, and the fetal heart rate is still 90 bpm. What should the nurse do next? Choose the best answer. a. Hand the physician a Malmström vacuum and. prepare for another round of 3 attempts b. Prepare for a forceps delivery c. Prepare for an emergency cesarean delivery d. Prepare an amnioinfusion

ROA

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? a. LOA b. LOP c. ROA d. ROP

Inform the RN that your client may have ruptured membranes

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in? a. Perform a Fern test b. Inform the RN that your client may have ruptured membranes c. Check EFM for late decelerations d. Perform deep palpation of the client's abdomen

A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently

A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response? a. A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. b. Explain that you will have to call the physician and get an order to leave the fetal monitor off. c. Insist that the fetal monitor be used due to a lack of staff to adequately monitor her using any other method. d. Tell her that it is her decision, but that she will be placing herself and her baby at grave risk.

uterus

A cesarean delivery is a major surgery and carries with it many risks for complications. The most common complication is infection. At what site is the infection likely to occur? a. Vagina b. Urinary tract c. Uterus d. Rectus muscle wall

It is a measurement to determine if the pelvis size is adequate for a vaginal birth

A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response? a. "It is the measurement between the ischial tuberosity and the pubis." b. "It is a measurement to determine if the pelvis size is adequate for a vaginal birth." c. "It is the smallest diameter of the pelvic outlet." d. "It is the largest diameter of the pelvic outlet."

Third

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? a. First b. Second c. Third d. Fourth

Assess vital signs

A client has just received combined spinal epidural. Which nursing assessment should be performed first? a. Assess vital signs. b. Assess pain level using a pain scale. c. Assess for progress in labor. d. Assess for spontaneous rupture of membranes. e. Assess for fetal tachycardia

Administration of 500 mL of IV Ringer's lactate

A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management? a. Administration of 500 mL of IV Ringer's lactate b. Administration of 1000 mL of IV glucose solution c. Move the woman into a supine position d. Administration of aspirin

headache following anesthesia

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? a. passage of the drug to the fetus b. headache following anesthesia c. excessive contractions of the uterus d. increased frequency of micturition

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg

A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia? a. Maternal respirations decrease from 20 to 14 breaths/minute. b. Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. c. Maternal pulse increases from 78 to 96 beats/minute. d. Maternal temperature increases from 99° F (37.2° C) to 100° F (37.8° C).

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? a. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. b. Agree with the client, and administer the drug immediately to keep the pain manageable. c. Explain to the client that narcotics should only be administered an hour or less before birth. d. Refuse to administer narcotics because they can develop dependency in the client and the fetus.

gynecoid

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted? a. platypelloid b. gynecoid c. android d. anthropoid

urinary output

A client is being prepared for a scheduled cesarean delivery by the medical team. Which intervention will be most critical for the team to monitor in the first 24 hours post cesarean delivery? a. Urinary output b. Administration of sodium citrate c. Preparing for blood transfusion d. Maintaining IV access

instruct the client or her partner to perform light fingertip repetitive abdominal massage

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: a. lead the client through a series of visualizations to aid in relaxation. b. instruct the client or her partner to perform light fingertip repetitive abdominal massage. c. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. d. press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist.

Check the fetal heart rate

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? a. Check the fetal heart rate. b. Perform a vaginal exam. c. Notify the primary care provider immediately. d. Change the linen saver pad.

naloxone

A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication? a. indomethacin b. ampicillin c. naloxone d. epinephrine

frequency duration intensity

A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply. a. frequency b. duration c. status of membranes d. intensity e. activity of fetus

Stand next to the client at the side of the bed

A laboring client is restless and moving frequently in the bed. She appears to be more uncomfortable with the contractions but refuses pain medication when offered. The client's partner has left the room to stretch his legs. Which response by the nurse is most helpful? a. Stand silently at the back of the room. b. Stand next to the client at the side of the bed. c. Turn up the volume of music playing in the room. d. Turn on the television as a focal point

10:30 a.m

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? a. 10:05 a.m. b. 10:30 a.m. c. 11:15 a.m. d. 11:30 a.m.

The presenting part of the fetus The type of uterine incision Reason for the cesarean birth The fetal heart rate The mother's vital signs

A mother pregnant with her second baby is admitted to L&D for a vaginal birth after cesearean (VBAC). While obtaining an admission assessment, what important information is necessary for the labor and delivery nurse to obtain? Select all that apply. a. The presenting part of the fetus b. The type of uterine incision c. Reason for the cesarean birth d. The fetal heart rate e. The mother's vital signs

episiotomy

A new mother calls the clinic on her fourth day after delivery and reports difficulty urinating and defecating because of the perineal pain. What does the nurse suspect is causing these problems? a. trauma from a Foley catheter b. trauma from a cesarean birth c. episiotomy d. infection

Increased rates of cesarean sections

A nurse correctly recognizes which of the following as a current trend within the population of birthing women? a. More natural births with fewer medical interventions. b. Increased public funds for using doulas. c. Increased rates of cesarean sections. d. Decreased use of epidurals

allowing the woman time to be alone

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure? a. promoting the woman's feelings of control b. providing clear information about procedures c. allowing the woman time to be alone d. encouraging the woman to use relaxation technique

respiratory depression

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client? a. accidental intrathecal block b. respiratory depression c. postdural puncture (spinal) headache d. a failed block

Change maternal position to an upright or side lying position

A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement? a. Encourage the Valsalva maneuver. b. Change maternal position to an upright or side lying position. c. Administer exogenous oxytocin. d. Place the client in the lithotomy position

prenatal perineal massage using natural pushing techniques patience with the delivery process protecting the perineum immediately before birth

A nurse is preparing a prenatal class for a group of couples who are in their third trimester. When explaining methods which can be used to help decrease the need for an episiotomy, which methods should the nurse prioritize? (Select all that apply.) a. prenatal perineal massage b. using natural pushing techniques c. patience with the delivery process d. protecting the perineum immediately before birth e. speeding up the delivery process

frank

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? a. frank b. full c. complete d. footling

cervical dilation (dilatation)

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? a. regular contractions b. cervical dilation (dilatation) c. fetal movement through the birth canal d. placental separation

sudden gush of dark blood from the vagina

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? a. boggy, soft uterus b. uterus becoming discoid shaped c. sudden gush of dark blood from the vagina d. shortening of the umbilical cord

cervical dilation of 6 cm contractions lasting up to 60 seconds

A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phase based on which assessment findings? Select all that apply. a. cervical dilation of 6 cm b. contractions every 1 to 2 minutes c. cervical effacement of 90% d. contractions lasting up to 60 seconds e. strong desire to push

It distracts your brain from the sensations of pain

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? a. "It distracts your brain from the sensations of pain." b. "It causes the release of endorphins." c. "It blocks the transmission of nerve messages of pain at the receptors." d. "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

Anxiety can speed up the labor process

A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement? a. "Nurses can influence birth outcomes in a positive way." b. "Anxiety can speed up the labor process." c. "Anxiety can slow down the labor process." d. "Continuous labor support can result in better labor outcomes."

Fetal lung maturity

A nursing student correctly identifies which of the following as the most important predictor of fetal maturity: a. Pregnancy dated as completed at least 38 weeks of gestation b. Date that fetal heart tones were first heard c. Fetal lung maturity d. Cervical readiness

latent active transition

A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply. a. latent b. pre-labor c. active d. transition e. inactive

latent phase

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient? a. latent phase b. active phase c. transition phase d. none of the above

Not if you fulfill the criteria for vaginal birth after cesarean

A patient who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births? a. "All future births must be done through cesarean." b. "Not if you fulfill the criteria for vaginal birth after cesarean." c. "Your health care provider will let you know what kind of birth you can have." d. "Most women prefer cesarean births because they are quicker and cause less pain."

fetal back

A pregnant client at 32-week gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds? a. fetal back b. fetal head c. fetal shoulders d. fetal buttocks

Patient uses breathing techniques to control anxiety and pain during labor

A pregnant patient nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the patient during the delivery process? a. Patient requests pain medication throughout the labor process. b. Patient uses breathing techniques to control anxiety and pain during labor. c. Patient tolerates the use of sanitary napkins to absorb vaginal secretions during labor. d. Patient refuses complementary and alternative techniques to control pain during labor

Radiates from the back to the front

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? a. Radiates from the back to the front b. Slows when the woman changes position c. Occurs in an irregular pattern d. Lasts about 20 to 25 seconds

Cervical ripening is noted on examination

A primigravida has an office appointment at 39 weeks' gestation. Which assessment data is most definitive of the onset of labor? a. The mother reports frequent urination. b. The fetal head is engaged in the pelvis. c. Cervical ripening is noted on examination. d. Expulsion of the mucus plug.

Ensure cervix fully dilated

A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritize at this time? a. Evaluate maternal vital signs b. Ensure cervix fully dilated c. Evaluate fetal heart monitor d. Ensure empty urinary bladder

Presence of an indwelling catheter

A primigravida whose baby is presenting breech is scheduled to have a cesarean birth. Which of the following would you prepare her for postoperatively? a. Presence of an indwelling catheter b. Bed rest for the first 4 days c. Insertion of a nasogastric tube d. Separation from her infant for 72 hours

artificial rupture of membranes

A student observing in labor and delivery watches a physician introduce a hard plastic instrument with a hook on the end into the vagina during a digital examination. The physician proceeds to guide the hook to snag a hole into the membranes. This process causes the body to release prostaglandins, which induces labor and is known as which of the following? a. membrane stripping b. artificial rupture of membranes c. mechanical dilatation d. none of the above

latent phase of the first stage

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: a. latent phase of the first stage. b. active phase of the first stage. c. pelvic phase of the second stage. d. early phase of the third stage.

moderately strong contractions every 4 minutes, lasting about 1 minute

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? a. increased energy level with alternating strong and weak contractions b. moderately strong contractions every 4 minutes, lasting about 1 minute c. contractions noted in the front of abdomen that stop when she walks d. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

The skin incision will be just above her pubic hair

A woman having a cesarean birth will have a low cervical incision. Which of the following would you cite as an advantage? a. The uterine incision will be vertical. b. The skin incision will be just above her pubic hair. c. Because the cervix is cut, the operation proceeds rapidly. d. Because the fundus of the uterus is cut, the infant can be resuscitated rapidly.

The temperature of the water should be at least 105℉ (40.5℃)

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? a. "The warmth and buoyancy of the water has a nice relaxing effect." b. "I can stay in the bath for as long as I feel comfortable." c. "My cervix should be dilated more than 5 cm before I try using this method." d. "The temperature of the water should be at least 105℉ (40.5℃)."

cervical dilation of 2 cm or more

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? a. intact membranes b. cervical dilation of 2 cm or more c. floating presenting fetal part d. a neonatologist to insert the electrode

I want this baby to be a boy

A woman is admitted to a labor unit in active labor. Which assessment would alert you to the possibility that she may have difficulty accepting this child? a. "I'm so tired of being pregnant." b. "I haven't been able to sleep well lately." c. "I want this baby to be a boy." d. "I am so exhausted."

I respect your preference, whether it is to have medication or not

A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice? a. "That's wonderful. Medication during labor is not good for the baby." b. "Your health care provider is a man and has never been in labor; he may be underestimating the pain you will have." c. "I respect your preference, whether it is to have medication or not." d. "Let me get you something for relaxation if you don't want anything for pain."

Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth

A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. Which of the following would be your best response? a. "You will like cesarean birth so much that you will want repeat cesarean births in the future." b. "There is no way to predict that; it will depend on your individual uterine anatomy." c. "Yes. 'Once a cesarean always a cesarean' is a well-known rule." d. "Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth."

Cesarean birth will reduce pressure on the immature head

A woman whose fetus at 30 weeks of pregnancy is failing to thrive in utero is told her physician wants to deliver the baby by cesarean birth today. She asks the nurse why this would be preferred to a vaginal birth. Which of the following would be your best response? a. "There's not an advantage; it's just more convenient." b. "Cesarean birth will reduce pressure on the immature head." c."You will have reduced pain afterward." d. "Cesarean birth allows the placenta to deliver easier."

The injection is given in the space outside the spinal cord

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? a. "An injury is unlikely because of expert professional care given." b. "I have never read or heard of this happening." c. "The injection is given in the space outside the spinal cord." d. "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

the presentation, lie, and attitude of the fetus

A woman's perception of pain can differ according to all of the following except: a. her expectations and preparation for labor. b. the length of her labor. c. psychosocial, physiologic, and cultural influences. fear, anxiety, and self-efficacy. d. the presentation, lie, and attitude of the fetus.

Induced labor can result in higher costs for the delivery

An elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor? a. Induced labor can result in higher costs for the delivery. b. Induced labor decreases the need for interventions during labor and delivery. c. Induced labors are less painful and progress faster. d. Induced labor decreases the possibility of cesarean birth.

The client reports a pain level of 8. She has a low pain tolerance

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification? a. "The client is experiencing lower back pain and I gave a backrub." b. "I changed the client position from her back to her side." c. "The client reports a pain level of 8. She has a low pain tolerance." d. "I instructed the client to ring if she felt the need to move her bowels."

feelings of being frightened by the change in contractions

As a woman enters the second stage of labor, which would the nurse expect to assess? a. feelings of being frightened by the change in contractions b. reports of feeling hungry and unsatisfied c. falling asleep from exhaustion d. expressions of satisfaction with her labor progress

Kangaroo care

As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding? a. Providing pain relief for the mother b. Koala care c. Making sure the significant other holds the infant shortly after birth d. Kangaroo care

occiput

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? a. shoulders b. occiput c. brow d. buttocks

Braxton Hicks contractions usually decrease in intensity with walking

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? a. Braxton Hicks contractions get closer together with activity. b. Braxton Hicks contractions usually decrease in intensity with walking. c. Braxton Hicks contractions do not last long enough to be true labor. d. Braxton Hicks contractions cause "ripening" of the cervix.

encouraging the woman to ambulate

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? a. having the client breathe with contractions b. providing one-to-one support c. encouraging the woman to ambulate d. urging her to focus on one contraction at a time

The patient is not requesting pain medication

During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective? a. The patient is not complaining of leg cramps. b. The patient is not requesting pain medication. c. The patient is focusing on a painting during contractions. d. The patient asks for a cold compress at the end of a contraction.

At the time of placental delivery

During which time is the nurse correct to document the end of the third stage of labor? a. Following fetal birth b. When pushing begins c. At the time of placental delivery d. When the mother is moved to the postpartum unit

Postpartum hemorrhage

Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes? a. Normal for a cesarean section b. Postpartum hemorrhage c. Infection d. Another cause other than the birth

Neonatal depression is possible

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks? a. The client is more sensitive to preanesthetic medications. b. The client is less sensitive to inhalation anesthetics. c. Neonatal depression is possible. d. Fetal hypersensitivity to anesthetic is possible

Hemorrhage

Which is the most important nursing assessment of the mother during the fourth stage of labor? a. The mother's psyche b. Blood pressure c. Hemorrhage d. Heart rate

Turn her or ask her to turn to her side

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? a. Help the woman to sit up in a semi-Fowler's position. b. Turn her or ask her to turn to her side. c. Administer oxygen at 3 to 4 L by nasal cannula. d. Ask her to pant with the next contraction.

Identify how the client expresses labor pain

In providing culturally competent care to a laboring woman, which is a priority? a. Identify the decision maker within the family. b. Identify any cultural foods used prior to labor. c. Identify who is the support person during the labor. d. Identify how the client expresses labor pain.

Complete hand hygiene

In the labor and delivery unit, which is the best way to prevent the spread of infection? a. Use sterile gloves b. Limit vaginal examinations c. Complete hand hygiene d. Provide clean gloves in the room

Deep variable decelerations more than 60 bpm below the baseline with every contraction

It is most likely that the physician would consider performing an amnioinfusion if the EFM tracing shows which of the following? a. Consistent early accelerations, variability present, and occasional decelerations b. Flat line without variability and no decelerations c. Occasional mild variable decelerations and moderate variability present d. Deep variable decelerations more than 60 bpm below the baseline with every contraction

Increases risk of blood loss immediately after delivery

It was once thought that an episiotomy made the birth less painful and heal faster than a spontaneous laceration of the perineum. Research has not shown these assumptions to be true. What is another finding in the research on episiotomies? a. Causes loss of bowel control after the birth b. Increases risk of blood loss immediately after delivery c. Suturing of episiotomy increases sexual pleasure following delivery. d. Decreases risk of infection after delivery

8 or above

Mrs. Atkins is 40 weeks' pregnant by ultrasound, and the induction of labor is being discussed by Mrs. Atkins and her birth attendant. The birth attendant tells Mrs. Atkins, "I am going to do a pelvic exam so that I can assess your readiness for labor. I will obtain what is known as a Bishop Score, and it will tell me how ready you are to go into labor." What Bishop Score would indicate a favorable response to oxytocin-induced labor? a. 5 or below b. 6 or above c. 3 or below d. 8 or above

Does not hyperventilate

Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would you expect? a. Does not hyperventilate b. Uses accelerated breathing patterns continuously c. Refrains from using the pant-blow technique so she doesn't push d. Pants through each contraction as she pushes

+4

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? a. -5 b. 0 c. +1 d. +4

A urine dipstick test to check for protein

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? a. A blood culture to note any infection of the blood b. A urine culture to rule out a urinary tract infection c. An ultrasound to determine fetal age d. A urine dipstick test to check for protein

The client experiences a rupture of membranes

The client may spend the latent phase of the first stage of labor at home unless which occurs? a. The client passes the bloody show b. The contractions vary in length and intensity c. The client begins back labor d. The client experiences a rupture of membranes

acupressureacupressure

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy? a. acupressure b. acupuncture c. effleurage d. biofeedback

The analgesia will reduce the sensation of pain for a limited period of time

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best? a. "The analgesia will limit your ability to be out of bed without assistance." b. "The analgesia will block pain sensation and limit your ability to push." c. "The analgesia will reduce the sensation of pain for a limited period of time." d. "The analgesia will allow for a pain-free birth experience."

This may prolong labor and increase complications

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? a. This would cause fetal depression in utero. b. This may prolong labor and increase complications. c. The effects would wear off before birth. d. This can lead to maternal hypertension.

Assess and reposition the woman

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? a. Assess and reposition the woman. b. Notify the registered nurse. c. Notify the health care provider. d. Wait 2 minutes to review another tracing.

Assess the infant for trauma

The maternal health nurse assists the birth attendant in a forceps-assisted birth. After the birth of the infant, what is the nurse's priority? a. Assess the infant for trauma b. Increase the rate of oxytocin c. Assess the mother for bleeding d. Apply supplemental oxygen to the mother

The sutures are absorbable and do not need to be removed An ice pack may help decrease the pain

The maternal health nurse is caring for a laboring client who has required a midline episiotomy due to infant shoulder dystocia. Which postpartum teaching will the nurse need to include related to the client's episiotomy? Select all that apply. a. "The sutures are absorbable and do not need to be removed." b. "An ice pack may help decrease the pain." c. "The sutures will need to be removed at your first postpartum appointment." d. "Be sure to apply a topical antibiotic ointment to prevent infection." e. "Avoid sitting directly on the toilet when urinating to decrease pressure."

lie

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? a. presentation b. attitude c. lie d. position

Take no extra measures; prepare for a standard labor

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? a. Take no extra measures; prepare for a standard labor. b. Anticipate this client is a one-to-one registered nursing assignment. c. Notify the client's support person that the labor is typically long. d. Prepare for vital signs and fetal monitoring hourly

meperidine

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control? a. meperidine b. thiopental c. hydroxyzine hydrochloride d. secobarbital

Respiratory distress

The nurse is assessing a neonate after a ceserean delivery. Which most common complication should the nurse be prepared for? a. Respiratory distress b. Shoulder dystocia c. A facial nerve injury d. Hemorrhage

naloxone

Which medication is administered to reverse the depressant effects of opioids? a. naloxone b. meperidine c. butorphanol d. nalbuphine

Muscle rigidity

The nurse is assessing the client who received spinal anesthesia to deliver a healthy fetus. In reviewing the family history, malignant hyperthermia is noted. If noted in the client, which early symptom will the nurse notify the health care provider about immediately? a. Muscle rigidity b. Elevated temperature c. Bradycardia d. Decreased level of consciousness

reposition the client on either side

The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? a. notify the health care provider b. reposition the client on either side c. palpate for bladder fullness d. do nothing, this is benign

The completion of the third stage of labor

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize? a. The client's vital signs b. The end of recovery c. The completion of the third stage of labor d. The transition phase

The fetus is in the true pelvis and engaged

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? a. The client is fully effaced. b. The fetus is floating high in the pelvis. c. The fetus is in the true pelvis and engaged. d. The fetus has descended down the birth canal.

Fear related to impending surgery Powerlessness related to medical need for cesarean birth Risk for anxiety related to unanticipated circumstances surrounding birth

The nurse is caring for a client for whom a cesarean birth is indicated. The client is currently preoperative. Which client concern(s) should addressed in the plan of care? Select all that apply. a. Fear related to impending surgery b. Powerlessness related to medical need for cesarean birth c. Risk for anxiety related to unanticipated circumstances surrounding birth d. Risk for infection related to a surgical incision e. Risk for hemorrhage related to surgical procedure

Intermittent fetal heart rate auscultation

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring? a. Intermittent fetal heart rate auscultation b. Continuous external fetal monitor c. No monitoring needed d. Fetal scalp sampling

Longitudinal fetal

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? a. Longitudinal b. Transverse c. Obtuse d. Oblique

Ensure that emergency equipment is readily available

The nurse is caring for a laboring client who has been administered a regional block for pain management. What is the nurse's priority action? a. Ensure that emergency equipment is readily available b. Assess the client's pain at least once every 20 minutes c. Encourage the client to adopt a side-lying position whenever possible d. Monitor the client closely for nausea and vomiting

Continue to monitor the client and the FHR

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? a. Continue to monitor the client and the FHR b. Promptly inform the primary care provider c. Reposition the client d. Advocate for the client to have a vaginal examination

Abdominal texture

The nurse is caring for a patient recovering from a cesarean birth. Which assessment should the nurse make a priority for this patient? a. Breast filling b. Plan to breastfeed c. Abdominal texture d. Perineum for edema

Whether her abdomen is soft or not

The nurse is caring for a woman who has had a baby by cesarean birth. Which of the following would be the most important assessment to make? a. Whether her abdomen is soft or not b. Whether her perineum is edematous c. If her breasts fill by the third day d. If she wants to breastfeed or not

Complete cervical dilation (dilatation) and time of fetal birth

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? a. Admission time and time of fetal birth b. Complete cervical dilation (dilatation) and time of fetal birth c. Effacement time and time when contractions are regular d. Time of mucus plug expulsion and full cervical dilation

My sister had a cesarean section with the first and then needs it for all subsequent pregnancies

The nurse is instructing a primipara who has concerns about the need for a cesearan section due to her sister's obstetrical history. Which statement by the client needs further instruction? a. My sister is tiny like me and was unable to have the baby fit through her pelvis." b. "My sister's baby was breech and was unable to be turned." c. "My sister was in labor for 24 hours and the labor did not progress." d. "My sister had a cesarean section with the first and then needs it for all subsequent pregnancies."

duration

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? a. duration b. intensity c. frequency d. peak

The client has saturated three sanitary napkins in the past 4 hours

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? a. The client states that she is having heavy bleeding. b. When ambulating the client to the bathroom, a gush of red blood was noted. c. The client has saturated three sanitary napkins in the past 4 hours. d. The client has lost 100cc of blood from what I approximate on her clothing.

A cephalohematoma

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? a. Wrapping of the head b. Developmental delay c. A cephalohematoma d. A caput succedaneum

Pain originates from the cervix and lower uterine segment

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor? a. Pain originates from the cervix and lower uterine segment. b. It is reported as the worst pain a woman will ever feel. c. Pain is focal in nature. d. Diffuse abdominal pain signals a complication with progression of labor.

Assess fetal heart rate

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? a. Assess maternal blood pressure. b. Assess for constipation. c. Assess for dry mouth. d. Assess fetal heart rate.

6.5

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? a. 5.0 b. 5.5 c. 6.0 d. 6.5

infection

The nursing instructor is conducting a class presenting the various aspects of a cesarean delivery. The instructor determines the class is successful after the students correctly choose which complication as the most common postoperative complication? a. Thrombosis b. Infection c. Laceration of the uterine artery d. Pneumonia

The woman is prepared for labor and birth

The pain of labor is influenced by many factors. What is one of these factors? a. The woman is prepared for labor and birth. b. The woman has a high tolerance for pain. c. The woman has a high threshold for pain. d. The woman has lots of visitors during labor.

reduces the risk of uterine rupture

The physician has just examined the patient and determined that she needs to have a cesarean section. He notifies the nurse that he will be doing a low cervical vertical incision into the uterus. The nurse knows that the physician has chosen this type of incision over the classical incision because the low cervical vertical incision: a. is larger than a classical incision and will allow for easier delivery. b. reduces the risk of uterine rupture. c. is less complicated to perform. d. has a lower risk of maternal injury

It can be administered by the nurse

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration? a. Fetal monitoring can be safely discontinued. b. It is generally given p.o. c. It can be administered by the nurse. d. It can be given frequently without risk to the fetus.

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? a. Women report higher levels of satisfaction when regional anesthetics are used to control pain. b. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. c. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. d. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain.

Lower risk for rectal mucosal tear

To prevent tearing of the perineum of a client during birth, a physician performs a mediolateral episiotomy. The nurse recognizes that an advantage of a mediolateral episiotomy over a midline episiotomy is which of the following? a. Lower risk for rectal mucosal tear b. Easier healing c. Less blood loss d. Less postpartal discomfort

The client's cervix is fully dilated

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? a. The client's cervix is fully dilated. b. The infant is born. c. The client has contractions once every two minutes. d. The client experiences her first full contraction

starting an IV and hanging IV fluids

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? a. administrating IV ephedrine b. administrating IV naloxone c. maintaining the client in a supine position d. starting an IV and hanging IV fluids

Fetal lie

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? a. Fetal presentation b. Fetal attitude c. Fetal position d. Fetal lie

degree of thinning

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? a. extent of opening to its widest diameter b. degree of thinning c. passage of the mucous plug d. fetal presenting part

prolonged decelerations

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? a. variable decelerations b. prolonged decelerations c. early decelerations d. accelerations

Tell me how you handled labor pain in your past deliveries

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies? a. "Tell me how you handled labor pain in your past deliveries." b. "How do you want the health care team to plan your care?" c. "Who do you want to be with you when you are in labor?" d. "Picking from these options, what options do you feel is best?"

The client will direct her pain management techniques

When developing a labor plan with the client, which outcome is the priority? a. The client will deliver the fetus vaginally. b. The client will be pain-free during the labor process. c. The client will direct her pain management techniques. d. The client will attend all prenatal classes prior to delivery.

Positive reinforcement

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most? a. Positive reinforcement b. Their significant other beside them c. Intense nursing care d. Just to be left alone

The characteristics of labor pain follow a pattern

When planning a labor experience for a primigravida, understanding which characteristic of labor pain is most helpful? a. All pain is the same. b. The characteristics of labor pain follow a pattern. c. Women innately know how to deal with labor pain. d. If the woman is in too much pain, a cesarean section is an option.

effacement

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? a. crowning b. effacement c. dilation (dilatation) d. molding

Absent accelerations Late deceleration patterns Persistent bradycardia

Which assessment findings indicate a distressed fetus? Select all that apply. a. Absent accelerations b. Fetal heart rate baseline of 140 c. Late deceleration patterns d. Persistent bradycardia d. Moderate fetal heart rate variability

Descent

Which cardinal movement of delivery is the nurse correct to document by station? a. Descent b. Flexion c. Extension d. Internal rotation

Hyperventilation

Which complication occurs as a result of ineffective breathing patterns? a. Hiccups b. Nausea c. Flatus d. Hyperventilation

Fetal heart rate in relation to contractions

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. Fetal heart rate in relation to contractions b. The station in which the fetus is located c. Maternal heart rate and blood pressure d. Maternal request for pain medication

scalp edema

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? a. vaginal lacerations b. increased intracranial pressure c. cervical lacerations d. scalp edema

Administering narcotic pain medication

Which nursing action has a negative effect on fetal descent? a. Laying the client on the left side b. Using a tap water enema c. Administering narcotic pain medication d. Walking the client in the hall

Have a blue bulb suction and an infant warmer ready

Which nursing action is a priority when the fetus is at the +4 station? a. Have a blue bulb suction and an infant warmer ready b. Have a tocometer and a patient gown ready c. Provide lubricating jelly and an internal monitor d. Prepare for an immediate cesarean section

Giving a fluid bolus of 500 ml

Which nursing action is required before a client in labor receives an epidural? a. Giving a fluid bolus of 500 ml b. Checking for maternal pupil dilation c. Testing maternal reflexes d. Observing maternal gait

Placing a wedge under the hips

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? a. Rubbing the client's legs b. Placing a wedge under the hips c. Providing a paper bag d. Massaging the client's lower back

Blood flow to the fetus improves Fetal heart rate should return to baseline

Which occurs as a result of contraction decrement? Select all that apply. a. The mother feels the contraction intensifying. b. Blood flow to the fetus improves. c. The fetus is pushed down the birth canal. d. Fetal heart rate should return to baseline. e. The mother feels a gush of water in the perineal area.

Difficulty breathing

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? a. Difficulty breathing b. Staggering gait c. Decreased level of consciousness d. intense pain

Vaginal examination

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? a. Urinalysis b. Vaginal examination c. Leopold maneuver d. Nonstress test

Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn

Which statement is true regarding analgesia versus anesthesia? a. Analgesia and anesthesia perform the same function when it comes to blocking pain. b. Increased FHR variability is a common side effect when regional anesthesia is used. c. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. d. Hypertension is the most common side effect when systemic analgesia is used.

Tachycardia and a falling blood pressure

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? a. Tachypnea and a widening pulse pressure b. Tachycardia and a falling blood pressure c. Bradycardia and auscultation of fluid in the base of the lungs d. Bradypnea and hypertension

Interference with blood coagulation with increased risk of bleeding in mother or infant

Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor? a. Competition with bilirubin-binding sites in fetal circulation increases risk of kernicterus b. Development of respiratory depression in the newborn c. Interference with blood coagulation with increased risk of bleeding in mother or infant d. Interference with the ability to concentrate on contractions

Cervical dilation of 1 cm

With which findings would the nurse anticipate a diagnosis of false labor? a. Regular contractions 8 minutes apart b. A feel of pressure in the pelvic region c. Cervical dilation of 1 cm d. Softening of the cervix