Chapter 66 Normal Labor Delivery Exam

The nurse is caring for a laboring woman who has been given oxytocin to induce labor. She is having contractions at an interval of every 2 minutes with 90 seconds duration in between them. What would be the appropriate intervention in this situation?

The nurse is caring for a laboring woman who has been given oxytocin to induce labor. She is having contractions at an interval of every 2 minutes with 90 seconds duration in between them. What would be the appropriate intervention in this situation?

Tell the nourishing client that menstruation should resume in 6 to 8 weeks

The nurse is discharging a new mother from the hospital. Which recommended teaching guideline should be discussed?

"IV hydration helps prevent the blood pressure from dropping too low."

The nurse is preparing a woman for epidural anesthesia. The woman asks, "Why is my IV running so fast? it feels cold!" What reply by the nurse is best?

Breast milk is readily available and convenient Breast milk contains antibodies Breast milk is always the right temperature

The nurse is teaching a new mother about the advantages/disadvantages of breastfeeding versus formula feeding. Which statements accurately describe the process? (Select all that apply.)

Red

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia charcateristic should the nurse expect to note?

Thrombophlebitis

The nurse performing a postpartum assessment on a client to elicit the Homans sign. For what condition is the nurse assessing?

The fetal head is at the vaginal opening

The obstetrical nurse checks the station of a laboring pregnant woman and documents +5 on the client chart. What does this number mean in terms of the delivery?

For labor induction: Initial dose of 1 to 2 mU; increased 1 to 2 mU/min until an adequate labor pattern is achieved

The obstetrical nurse is administering oxytocin for her client to induce labor. Which guideline is recommended for administration of the drug?

The placenta is expelled with the dull side out

The obstetrical nurse records the expulsion of the placenta in stage III labor as a Duncan presentation. What does this data represent?

true

_____ a breech presentation is considered abnormal, making of complicated labor

false

_____ contractions lasting 4-5 minutes are considered safe and should not be reported to the physician

false

a birth plan can include a woman's choice of support partner during labor and the type of pain relief measures denied

true

in true labor, the involuntary uterine contractions are rhythmic and grow stronger over time

Assist the woman to blow at the peak of contractions.

A primipara is dilated 8 cm and is completely effaced at a +1 station. She tells the nurse, "I can't keep myself from pushing when I have a contraction." What intervention is most appropriate in this situation?

"It is best to learn and use several methods of pain relief to find the one that works best for you."

A woman asks the nurse during a prenatal office visit, "What pain relief method is best during labor?" What answer by the nurse best answers the question?

Third

A woman has just delivered a healthy baby girl, but the placenta has not yet delivered. What stage of labor does this scenario represent?

"It is believed that several factors work together to stimulate labor to begin."

A woman near the end of pregnancy comments to the nurse, "I'm curious. What causes labor to begin?" Which reply by the nurse is best?

Fern test

A woman presents to the labor suite and states, "I have water leaking down my legs." What assessment is most appropriate in this situation?

At the level of the umbilicus

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

Encourage bonding with the infant

The nurse is caring for a client who just delivered a healthy 7 lb 9 oz baby girl. What is the priority nursing intervention for this new mother?

Power

A 2-year-old woman is dilated 4 cm. The physician states that she has a roomy pelvis, and the baby is in a right occiput anterior (ROA) position at a +1 station. Her contractions are occurring every 10 min-utes, lasting 30 to 40 seconds, and palpate mild in intensity. she is calm and relaxed. Given these data, the nurse knows which essential component of labor is unexpected and likely to slow the progress of labor at this time?

"I'm so glad that I won't have any pain because I'm going to have an epidural."

A 22-year-old gravida 2, para 0 is in the doctor's office for a checkup at 36 weeks' gestation. Which comment by the woman indicates that she needs additional information about pain relief during labor?

10:30

A G1 P0 is in the active phase of labor. she is a low- risk patient. You evaluate the fetal monitor strip at 10 am. Moderate variability is present. The FHR is in the 130s with occasional accelerations, no decelerations. At what time do you need to reevaluate the FHR?

Explain that she will need to be on the monitor for a few minutes to be certain this baby is doing well. After this initial assessment, 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. She says that she delivered her second baby at home without a monitor and everything went well. How do you plan to handle this situation?

Vertex presentation

A client is in labor, and the nurse palpates her abdomen to assess the presentation of the fetus. Which presentation indicates normal labor?

The type of episiotomy on the client's chart

A client is in the second stage of labor. The nurse should record the following information in the second stage:

Change the woman's position and give oxygen

A fetus is experiencing variable decelerations in the fetal heart rate during contractions. What is the appropriate nursing intervention for this situation?

White or cloudy amniotic fluid

A nurse is assessing a pregnant client whose membranes have ruptured. Which finding may indicate an infection?

Maternal fever

A nurse is assisting in the care of a client who is in active labor. The nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

Fetal engagement

A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotiomy?

Birthing room

A nurse is informing a client about different choices available to pregnant women choosing a birth setting. Which birth setting promotes safe, satisfying, and the most cost-effective childbirth?

moderate

A nurse is inspecting the perineal pad of a client who is 24 hr postpartum. The pad is saturated with approximately 12 cm of dark-red discharge. Which of the following blood loss estimations should the nurse report to the charge nurse and document in the client's medical record?

Sore nipple with cracks and fissures

A nurse is reinforcing discharge instructions with a client who is 4 weeks postpartum. The nurse should instruct the client to contact her provider for which of the following findings?

kegal exercises

A nurse is reinforcing discharge teaching with a postpartum client following a cesarean birth. The client reports leaking urine every time she sneezes or coughs. Which of the following interventions should the nurse suggest to the client?

External monitoring cannot measure intensity of contractions

A nurse is reinforcing teaching about external monitoring with a client who was recently admitted for induction of labor. Which of the following information should the nurse include?

"It can detect abnormal fetal heart tones early." "It allows for accurate readings despite maternal movement." "It can measure uterine contraction intensity."

A nurse is reinforcing teaching with a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (Select all that apply.)

Stage I, active phase

A pregnant woman is having moderately strong contractions every 3 minutes lasting 50 seconds. Her cervix is dilated 6 cm. What state of labor is she expecting?

Certified nurse midwife

A pregnant woman stats that she wants to have her baby at home on her "own territory." What type of professional would be most likely to attend a home birth?

"This feeling is called lightening and means that the fetus has settled into the pelvis."

A primigravida who is 2 weeks away from her delivery date tells the obstetrical nurse that she feels like "the baby has dropped." What would be the nurse's best response to this client?

Determine the fetal heart rate

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Report the situation to the practitioner

Following delivery, a client feels the urge to void, but is unplayed to do so after an extended period of time. What immediate action should the nurse take?

ROA

The fetus is 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?

Asking the woman to describe her pain and rate it on a scale of 0 to 10.

The labor nurse reports to the nurse on the oncoming shift, "The woman in labor room 2 is handling her pain very well. she smiles whenever I go in to talk to her, and she doesn't complain at all." What assessments by the oncoming labor nurse would best reveal if the off going labor nurse's observations were correct?

Delivery of the baby through the vaginal opening

The nurse assessing a laboring client documents that the client is in stage II of labor. What typically occurs during this stage?

Baseline fetal heart rate

The nurse assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

"Lochia serosa, which is pink or brown tinged, starts after the bleeding diminishes."

The nurse caring for a postpartum client explains the occurrence of lochia following deliver. Which statement accurately describes a characteristic of this process?

Determine the maternal and fetal vital signs

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially?

A woman whose baby is in the footling breech position

The nurse is assisting with deliveries is aware that which clients are most at risk for having a difficult delivery and possibly cesarean section?