318 week 3 prep u

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: baseline FHR. short-term variability. baseline variability. fetal bradycardia.

baseline FHR.

A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? cephalhematoma asphyxia central nervous system injury clavicular fracture

cephalhematoma

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? cervical lacerations caput succedaneum infection of episiotomy perineal hematoma

cervical lacerations

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? administration of morphine sulfate darkening room lights and decreasing noise and stimulation administration of oxytocin cesarean birth

cesarean birth

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 15 minutes every 10 minutes every 5 minutes every 20 minutes

every 15 minutes

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? fetal position external electronic fetal monitoring fetal oxygen saturation fetal blood pH

external electronic fetal monitoring

A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which should the nurse monitor the fetus? coagulation defects fetal hypoxia placental pathology preeclampsia

fetal hypoxia

The nurse would be alert for possible placental abruption during labor when assessment reveals which finding? gestational hypertension low parity macrosomia gestational diabetes

gestational hypertension

What terminology would the nurse use to document a newborn who weighs 4,000 grams (8.13 lb) or more at birth? microsomia macrosomia hydrocephalus meconia

macrosomia

A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia? betamethasone magnesium sulfate indomethacin nifedipine

magnesium sulfate

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid? midazolam hydroxyzine nalbuphine naloxone

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? naloxone ampicillin indomethacin epinephrine

naloxone

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant? patent airway ability to arch the eyebrows ability to swallow fluids palpation of the anterior fontanels

patent airway

When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's firstaction would be to: place her in a knee-chest position. turn her to her left side. cover the exposed cord with a dry, sterile wrap. replace the cord with gentle pressure.

place her in a knee-chest position.

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating? dystocia preterm labor macrosomia normal labor

preterm labor

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? respiratory depression urinary retention abdominal distention hyperreflexia

respiratory depression

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed? muscle relaxants tocolytic therapy anti-anxiety therapy bronchodilators

tocolytic therapy

A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication? uterine rupture an undiagnosed abdominal aorta aneurysm an amniotic embolism to the lungs compression on the inferior vena cava

uterine rupture

The nurse in an obstetric clinic is conducting client education with a group of expectant mothers. One young woman asks the nurse to tell the group what labor pain is like. What would be the nurse's best response? "It has been described as the worst pain you will ever feel." "It is best evaluated by talking with visitors in the labor room because they know you best." "The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in." "It comes in waves."

"The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in."

A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide? "You have an infection and need antibiotics." "Green might be a yeast infection and we need to culture the discharge." "This is meconium-stained fluid from the baby." "Amniotic fluid is normally green."

"This is meconium-stained fluid from the baby."

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: +2 station. 0 station. crowning. -2 station.

-2 station.

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? Change maternal position to an upright or side lying position. Place the client in the lithotomy position. Administer exogenous oxytocin. Encourage the Valsalva maneuver.

Change maternal position to an upright or side lying position.

A pregnant woman gives birth to a term fetus who has died in utero. She requests time after the birth to hold her baby. What is the best response by the nurse? "You don't want to see your baby like this. I will take the baby away for you." "Hold your baby as long as you like. Please let me know what I can do to help you." "This was nature's way of taking care of a defective baby." "You can hold your baby for a few minutes, but then I must take it to the nursery to do the paperwork."

"Hold your baby as long as you like. Please let me know what I can do to help you."

Before calling the primary care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider? Make sure the client is lying on her left side. Assess vital signs every 30 minutes. Make sure the epidural medication is turned down. Check for a full bladder.

Check for a full bladder.

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

Complete hand hygiene

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate? "Why would you do something as stupid as that?" "Please talk to your primary care provider first to ensure it is safe." "Personally, I would use them, but I cannot tell you to." "There is no scientific evidence they work. You will just complicate your situation more."

"Please talk to your primary care provider first to ensure it is safe."

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention? The mother is unable to void after 4 hours. Maternal tachycardia and falling blood pressure Dark red lochia Placental separation 15 minutes after birth

Maternal tachycardia and falling blood pressure

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth? fundal pressure positioning the woman prone Lamaze position McRoberts maneuver

McRoberts maneuver

A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure? To decrease the heart rate of the fetus To prevent supine hypotension syndrome To aid the woman as she pushes during labor To prevent the woman from falling out of bed

To prevent supine hypotension syndrome

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: a possible infection. meconium passage. normal. transient fetal hypoxia.

a possible infection.

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? effleurage acupuncture acupressure biofeedback

acupressure

A woman whose fetus in in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? performing acupuncture on the back applying counter pressure to the back applying ice to the back applying a heating pad to the back

applying counter pressure to the back

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse? "This is just a normal part of labor." "Perhaps you have been in one position for too long." "Let me help you out of bed to try walking it off." "Different fetal positions can cause prolonged labor and back pain."

"Different fetal positions can cause prolonged labor and back pain."

Fetal heart rate monitoring reveals baseline tachycardia in the fetus. Which rate would be mostlikely? 144 beats per minute 134 beats per minute 164 beats per minute 154 beats per minute

164 beats per minute

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? Delay breastfeeding the newborn for a day. Assess uterine tone to determine fundal firmness. Avoid early ambulation to prevent respiratory problems. Ensure that the client does not cough or breathe deeply.

Assess uterine tone to determine fundal firmness.

A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation? Decreased strength of uterine contractions Decreased fetal oxygenation Increased risk for placental abruption Increased risk for infection

Decreased fetal oxygenation

A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? Assess to see if the client has any drug allergies. Determine if the client is in true or false labor. Ask if this is the client's first pregnancy. Notify the healthcare provider.

Determine if the client is in true or false labor.

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? Pain pathway blockage Abdominal imagery Massage Effleurage

Effleurage

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Prepare the woman for an emergency cesarean birth. Help the woman change positions. Document the finding. Obtain assistance to check for a compressed umbilical cord.

Help the woman change positions.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? Inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds. Hold breath for 5 seconds after every 3 breaths. Inhale slowly through nose and exhale through pursed lips. Punctuated breathing by a forceful exhalation through pursed lips every few breaths.

Inhale slowly through nose and exhale through pursed lips.

The nurse cared for a client who delivered. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record? Precipitous labor False Labor Prodromal labor Prolonged labor

Precipitous labor

A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement? Assist in providing epidural anesthesia. Provide emotional and physical support. Assist in preparation for a cesarean birth. Administer the drug naloxone.

Provide emotional and physical support.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor? Provide ongoing communication about what is happening. Hold all explanations until after the birth to conserve the woman's energy. Tell her not to feel anxious or discouraged about what is happening. Limit talking to things the woman asks questions about.

Provide ongoing communication about what is happening.

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider? Respiratory depression, hypotension, absent tendon reflexes Severe lower back pain, leg cramps, sweating Low potassium or elevated glucose, tachycardia, chest pain Pain in the abdomen, shoulder, or back

Respiratory depression, hypotension, absent tendon reflexes

Which neonatal assessment is the highest priority if the mother received meperidine during labor? Lung sounds Respiratory rate Temperature regulation Time of first meconium

Respiratory rate

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? alert level of consciousness respiratory rate of 16 breaths per minute urine output of 45 mL/hour diminished deep tendon reflexes

diminished deep tendon reflexes

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration? prolonged decelerations variable decelerations late decelerations early decelerations

variable decelerations