Practice questions w/ answers and rationales set 2
The Dr orders the following med for a laboring client: Stadol 0.5 mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of the med will the nurse administer? calculate to the nearest hundredth
-0.25 mL mL = 1mL x 0.5mg = 0.5 mL 2mg = 2 answer = 0.5/2 = 0.25 mL
A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that client is at this time?
-2 cm
While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability w/ a baseline of 142 bpm. What should the nurse do?
-provide caring labor support rationale: this is a normal FHR
A client is complaining of severe back labor, which of the following nursing interventions would be the most effective?
-provide sacral pressure rationale: this provides counteraction to the pressure being exerted by the fetal head
The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care?
-provide the woman w/ a long-sleeved hospital gown rationale: Observant Jewish women are expected to have their elbows covered at all times.
A multipara, LOA, station +3, who has had no pain meds furing her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate?
-the baby is going to be born very soon, it is really too late for an epidural rationale:average length of the second stage is about 15 minutes and an epidural takes about 20 minutes to take effect
The childbirth educator nurse is evaluating the learning of 4 women, 38-40 weeks gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements?
-the client who says "If I feel a pain in my back and lower abdomen every 5 min" -the client who says "When I feel a gush of clear fluid from my vagina" -the client who says "If I ever notice a greenish discharge from my vagina"
A woman, 40 weeks, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital?
-the contractions are about a minute long and I am unable to talk through them
After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding?
-the fetus has a healthy nervous system rationale: moderate variability is indicative of fetal health
The Dr writes the following order for a newly admitted client in labor: Begin a 100 mL IV of D5 1/2 NS at 150 mL/hr. The IV tubing states that the drop factor is 10 gtt/mL. Calculate the drip rate to the nearest whole
-25 gtt/min gtt = 10 gtt x 150 mL x hr = 1500 gtt min= mL hr 60 min =60 answer = 1500/60 = 25 gtt/min
A nurse is caring for women from 4 different countries. Which of the women is most likely to request that her head be kept covered throughout hospitalization?
-Arabic women
A woman is in the transition phase of labor, which of the following comments should the nurse expect to hear?
-I cant stand this pain any longer
A nurse is caring for a laboring woman who is in transition, which of the following s/s would indicate that the women is progressing into the second stage of labor?
-a bulging perineum -bloody show -uncontrollable urge to push
The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal?
-baseline of 140-150 w/ decelerations to 100 that mirror each of the contractions rationale: these are r/t head compression w. are expected during the transition and second stage of labor
A woman in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitoring tracing?
-decreased variability rationale: analgesics are CNS depressants causing a decreased variability
On vaginal examination, it is noted that a woman w/ a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline FHR is 130 w/ no decels. Which of the following nursing actions is appropriate at this time?
-delay pushing until the baby descends further and the mother has a strong urge to push
immediately following an administration of an epidural anesthesia the nurse must monitor the mother for which of the following?
-drop in BP rationale: common side effect of regional anesthesia
A woman is in the second stage of labor w/ a strong urge to push. Which of the following actions by the nurse is appropriate at this time?
-encourage the woman to grunt during contractions rationale:the woman should push on an open glottis to prevent the vasovagal response
A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform?
-evaluate the progress of labor rationale: to determine if the client moved into the second stage of labor (transition in multiparas last appx 10 minutes)
The nurse is assessing a client who states "I think I am in labor" which of the following findings would positively confirm the client's belief?
-her cervix had dilated from 2-4 cm rationale: this is a true indication of labor
The nurse auscultates a FHR of 152 on a client in early labor. Which of the following actions by the nurse is appropriate?
-inform the mother that this rate is normal rationale: normal FHR is 110-160 bpm
Which of the following actions is appropriate for the nurse to perform when caring for a Chinese woman in active labor?
-inquire regarding the woman's pain level rationale: Chinese women are often expected to be quiet during labor even when in severe pain, thus making it essential to repeatedly question them regarding their pain level
The nurse wishes to assess the variability of the FHR. Which of the following actions is recommended prior to performing this assessment?
-insert an internal fetal monitor electrolode rationale: before the variability can be accurately assessed an internal fetal heart electrolode should be applied
A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for?
-lengthening of the umbilical cord -uterus rising in the abdomen and feeling of globular rationale: these are signs of placental separation
Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse perform during the next contraction?
-monitor for signs of rectal pressure rationale: it is best practice to wait until the woman exhibits signs of rectal pressure bc pushing a baby that is not yet fully engaged may result in overly fatigued woman or prolapsed cord
The nurse enters a laboring client's room, the client complains of intense back pain w/ each contraction. The nurse concludes that the fetus is likely in which of the following positions?
-occiput posterior
While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time?
-the relationship between the decels and labor contractions rationale:this determines the type of deceleration present
During the third stage of labor, what physiological changes occur?
-the uterus contracts firmly -the uterine surface area dramatically decreases -membranes separate from the uterine wall -hematoma forms behind the placenta
A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude?
-the woman is about to deliver the placenta
A nurse concludes that a woman is in the latent phase of labor. Which of the following s/s would lead a nurse to that conclusion?
-the woman talks and laughs during contractions rationale:characteristic behaviors of latent phase
