PP RNSG 1538 Intrapartum Mastery Quiz

Instruct the client to use a pant-blow pattern of breathing.

A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next?

hands and knees

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief?

notify the supervisor of the unit.

While preparing medication for a client in labor, the observes a co-worker slipping a vial of morphine into their side pocket. The nurse should:

Instruct the client to go to an emergency room for an urgent assessment.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse?

Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg

A nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?

"I will make every effort to work with your cultural beliefs."

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict?

increase in the fetal heart rate and variability

The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose?

Leopold's maneuvers

The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month-pregnant woman performs which of the following actions?

Oxytocin

The nurse is assisting a client during the first stage of labor, who just received an epidural. Which medication will the nurse expect to administer next?

ruptured membranes

A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse understands that which condition is a contraindication to hydrotherapy?

"Alterations in cardiovascular function affect the fetus."

A client in active labor asks the nurse why her blood pressure is being monitored so frequently. Which of the following is an appropriate response by the nurse?

Discontinue the oxytocin if the uterus does not relax between uterine contractions.

A laboring client on oxyitocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings, which of the following would be the best action for the nurse?

The fetal monitor strip shows early decelerations.

A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks only Mandarin, and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which response indicates that the client may be approaching birth?

Begin continuous fetal heart rate monitoring.

A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. Which of the following activities should the nurse immediately perform?

complete a vaginal examination to determine dilation, effacement, and station.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:

"I will explain what is happening to guide you as we go along."

A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby is coming!" To help the client remain calm and cooperative during the imminent birth, which response by the nurse is most appropriate?

loss of control

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor?

evidence of spontaneous rupture of the membranes

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding?

client at 38 weeks' gestation with active herpes lesions

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?

Maternal heart rate 125 beats/minute

What assessment data of a laboring woman would require further intervention by the nurse?

pulmonary

When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal systems?

Provide gentle support to the fetal head.

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which action should the nurse do next?

Active

The nurse performs the initial assessment and reports the following findings to the physician: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage of labor?

Note the color, amount, and odor of the amniotic fluid.

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first?

ensures a more comfortable atmosphere for the client and labor

A 30-year-old multigravida pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when she says that an electronic monitor performs which function?

intrauterine infection.

A client at 36 weeks' gestation is admitted in preterm labor with a temperature of 101.2° F (38.4° C). She reports a steady dripping from the vaginal area and examination indicates that she's leaking amniotic fluid. A nurse realizes the probable cause of her fever is:

Spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. Which of the following does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

Fetal heart rate of 80 beats/minute

A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean birth may be necessary?

"If left untreated, my baby might be born with an infection."

A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the instructions when she says:

IV hydration. Maternal position change. Oxygen administration.

The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply.

Offering support by reviewing the short-pant form of breathing

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?

Assess the imminence of birth.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission?

hypotension

A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for:

lecithin-sphingomyelin (L/S ratio)

The health care provider (HCP) orders an amniocentesis for a primigravid client at 37 weeks' gestation to determine fetal lung maturity. Which is an indicator of fetal lung maturity?

"Suctioning will be needed if the baby is floppy."

The nurse instructs the client about the procedures that will be performed on the neonate immediately after birth to prevent meconium aspiration. The nurse determines that the instructions have been effective when the client states that which procedure will be done to her baby?

Excessive fetal activity and fetal tachycardia

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which finding would indicate fetal hypoxia?

Notify the healthcare provider immediately.

A client who has abruptio placentae exhibits cyanosis in her earlobes, capillary filling time >3 seconds, and reports "heartburn." Which of the following is the best nursing intervention?

Ask the client what fluids she prefers to drink.

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time?

Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR)

A physician placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?

Contractions will decrease in frequency, intensity, and duration.

A client is admitted at 30 weeks' gestation with contractions every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2 g/h. How will the nurse know the medication is having the intended effect?

intravenous penicillin

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe?

"The contractions do not seem as painful as before."

A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor and possible vaginal birth. After several hours of active labor, the primary care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which statement?

Collaborate with the physician to make a referral to social services.

A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?

Notify the physician that the husband has been waiting to discuss his wife's condition.

A client is hospitalized for severe preeclampsia and complete placenta previa. The husband tells the nurse that he is frustrated to have been waiting for 3 hours for the physician to discuss his wife's condition and plan of care with them. What is the nurse's most appropriate action?

Recognizing the family as active participants in their care

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family's birth plan?

relaxing uninvolved body muscles during uterine contractions

Which technique to promote active relaxation would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor?

perineum

A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions.

A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. The expected outcome of this drug is:

Inspect the perineum.

The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" What should be the nurse's first action?

beginning of one contraction to the beginning of the next contraction

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

passage of meconium by the fetus

The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding?

after the delivery of the placenta.

The third stage of labor ends:

the social worker on call.

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to:

engagement. descent. flexion. internal rotation.

A nurse is teaching a primipara and her partner about the labor and birth process. The nurse describes the maneuvers that the fetus goes through during the labor process when the head is the presenting part. Place the maneuvers below in the order in which the nurse should explain that they occur. All options must be used.

Massage the fundus.

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention?

"I should try to push with each contraction."

After explaining about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed?

exhaustion

For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:

An increased sense of rectal pressure

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

"The corticosteroids may help my baby's lungs mature."

Which statement by the client indicates an understanding of teaching regarding use of corticosteroids during preterm labor?