intrapartum
A nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which of the following?
Characteristics of contractions
The advantages of using spinal anesthesia for delivery of a fetus include which of the following? Select all that apply.
Ease of administration Absence of fetal hypoxia Immediate onset of anesthesia
A prenatal client with vaginal bleeding is admitted to the labor unit. Which of the following signs or symptoms indicates placenta previa?
Painless vaginal bleeding
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened?
support the mother in her reaction to the newborn infant.
The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated?
A change in the uterine contour
The nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?
Baseline fetal heart rate
A nurse is assigned to care for a nulliparous client who is having a precipitate delivery. The nurse reports which maternal focused observations?
Decreased periods of uterine relaxation between contractions
A primigravida's membranes rupture spontaneously. The nurse's first action is to:
Determine the fetal heart rate.
A nurse should prepare to give a prescribed oxytocic medication after delivery of the:
Placenta
A pregnant client has been diagnosed with placental abruption. The nurse caring for the client prepares the client for:
cesarean birth
A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is isolated:
1 cm above the ischial spines
A nurse assisting in the care of a woman in labor should focus primarily on which of the following at the time of delivery?
Infant
Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:
Is a systematic method for palpating the fetus through the maternal abdominal wall
A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs:
To regain her breathing pattern
A nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
changes in the shape of the uterus
A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?
contraction stress test
A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include:
Shoulder dystocia
In providing initial care to the newborn following delivery, the priority action of the nurse is to:
Turn the infant's head to the side.
A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:
Notify the registered nurse (RN) immediately.
A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is:
1 cm above the ischial spines
A nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document that the FHR is normal if which of the following were noted?
150 beats per minute
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which of the following nursing actions is appropriate?
Notify the registered nurse (RN).
A nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which of the following at this time?
Notify the registered nurse of a possible maternal infection.
A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?
Pain level is "4" while a progressive labor pattern continues.
A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Considering the client's behavior, the nurse suspects she is dilated:
8 to 10 cm
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is:
A manual pelvic examination
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection?
Respirations of 10 breaths per minute
A nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor:
All vital signs, especially heart rate and blood pressure
A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid doing which of the following at this time to assist in relieving the back discomfort?
Assist the client to ambulate in the room.
A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. The nurse's initial action is to:
Gently hold the presenting part upward.
A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?
Betamethasone
Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?
Change in uterine shape
A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately:
Checks the fetal heart rate
A nurse assists the nurse-midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (−) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity for the client?
Complete bedrest
A nurse in the labor room is caring for a client in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?
Document the findings and continue to monitor the fetal patterns.
A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client's feelings of anxiety by:
Encouraging the client to discuss her concerns and desires regarding anesthesia options
A client in labor asks the nurse why it is so important to void frequently during labor. The nurse responds, using knowledge that the important reason is to:
Ensure labor progress and prevent injury.
A nurse is caring for a woman in the delivery room. The health care provider prescribes an oxytocic medication for the woman to stimulate uterine contractions and prevent hemorrhage. The nurse understands that this medication will be administered after delivery of the:
Placenta
After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of:
Placental separation
A nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.
Signs of fetal distress High level of maternal anxiety Failure of the fetus to descend
A nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for:
Signs of shock
A nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse would first:
Stop the oxytocin infusion.
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in the:
Supine position with a wedge under the right hip
A nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which of the following findings is least likely associated with DIC?
Swelling of the calf of one leg
A nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?
Turn client to her side and administer oxygen by mask at 8 to 10 L/min.
When examining the umbilical cord immediately after birth, the nurse expects to observe:
Two arteries
A nurse is preparing a client for an emergency cesarean delivery. Which of the following information regarding the client has priority?
When was the last time the client ate or drank?
A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?
White blood cell count of 35,000 mm3
A nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?
With the hips elevated
The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?
Left lateral
A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse initially include in the plan of care?
Maintain complete bedrest, monitor IV fluid intake, and monitor the fetal heart rate.
A nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:
Prevent dehydration and hypoxemia.
A nurse is assigned to assist in caring for a client in labor. The nurse would determine that which of the following would least likely indicate dystocia?
Progressive changes in the cervix
A nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing:
Complete placenta previa
The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client?
Measuring the fundal height
A nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which of the following at this time?
Continue monitoring the client because the data reflect acceptable progress.
A nurse is caring for a client in preterm labor when her membranes rupture. The initial nursing action is to:
Monitor the fetal heart rate.
The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. The nurse should:
Continue to assess vital signs and fetal heart rate the same as before the nerve block.
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. This action will primarily:
Assist in preventing dehydration and hypoxemia.
The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. Select all that apply.
Bright red vaginal bleeding Soft, relaxed, nontender uterus
A nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?
Monitoring fetal status
The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment:
Is effective in protecting the newborn from Neisseria gonorrhoeae and chlamydia
A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage:
Is light stroking of the abdomen to facilitate relaxation during labor
Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal?
It is pale, straw-colored with flecks of vernix.
A nurse is assigned to care for a client experiencing dystocia. In planning care, the nurse would consider the highest priority to be frequent:
Monitoring for changes in the physical and emotional condition of the mother and fetus
A nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?
Lateral Sims'
A client in preterm labor is placed on bedrest. The nurse assists the client to which of the following advantageous positions?
Left lateral
A nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following most appropriately describes the mother's problem at this time?
Fear about what is happening
A nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as:
Fear of losing control
A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which of the following findings would indicate a need to contact the registered nurse (RN)?
Fetal heart rate of 180 beats per minute
A nurse is assisting in performing Leopold's maneuvers. When the client asks what these are for, the nurse's best response is that these maneuvers help to determine:
Fetal position
Of the following, which would be the appropriate method to use to deliver the placenta after a precipitate delivery?
Gently guide the placenta out after a spontaneous separation.
A client delivers a viable male neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be:
Good
A nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
Have the client empty her bladder.
A nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client says:
My cervix is completely dilated."
For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes, lasting 60 to 70 seconds, and strong to palpation. She is 2 cm dilated and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?
Hypertonic
A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding?
Increase in fundal height
A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will likely have:
Increased efficiency of contractions
A nurse is monitoring a client in labor whose membranes rupture spontaneously. The initial nursing action is to:
Determine the fetal heart rate.
A nurse assisting to monitor a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client to reflect an attitude of:
Excitement
A nurse caring for a client diagnosed with placental abruption would plan to:
Prepare the client for a cesarean birth.
A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. What is the appropriate nursing action?
Prepare the client for a cesarean delivery.
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted?
Presence of accelerations
A nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:
Provide pain relief measures.
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. What is the appropriate action to deliver the placenta?
Pull gently on the cord as the mother bears down.
If a precipitate delivery is imminent, which of the following would be the appropriate nursing action?
Put on sterile gloves, and gently guide the baby's head and shoulders out.
A nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
A nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that its primary purpose is to:
Reduce the risk of injuring the bladder during the surgery.
A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?
Report the time of last food intake to the health care provider
The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:
determine the maternal and fetal vital signs.
A nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which of the following at the client's bedside?
intravenous (IV) supplies
The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?
Continue to monitor the client.
A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted?
Fetal tachycardia
A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply.
Flushing Depressed respirations Extreme muscle weakness
A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse includes which of the following in the plan of care?
Maintain continuous electronic fetal monitoring.
The maternity nurse prepares the client for which of the following techniques commonly used to relieve shoulder dystocia?
McRoberts' maneuver
A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which of the following information would be of concern to the nurse?
Respirations of 10 breaths per minute
A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines that the client's primary physiological need at this time is:
Rest between contractions
At 5:00 AM a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 AM with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to:
Prepare the client for a cesarean delivery.
The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the:
Supine position with a wedge under the right hip
