Labor & Birth quiz
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
"It sounds like you are feeling sad that things didn't go as planned"
A nurse in l&d is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
2 arteries 1 vein
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?
A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
A client who is at 28 weeks of gestation and reports of painless vaginal bleeding
A nurse is caring for a client during a non stress test (NST). At the of a 30 min period of observation, the nurse notes the following findings: the fetal heart baseline is 120/min with minimal variability and no accelerators. There are two decelerations of 15/min in the fetal heart during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these finding should the nurse make?
A nonreactive test
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?
A surge of energy
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?
An excessive amount of amniotic fluid is present
A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?
Apply perineal pressure to the emerging fetal head
A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is a priority action by the nurse following the procedure?
Assess the fetal heart rate
A nurse is caring for a client who is to undergo an amniotomy. Which the following is the priority nursing action following this procedure?
Assess the fetal heart rate pattern
A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temp is 38.9C (102F). Besides notifying the provider, which the following is an appropriate nursing action?
Assess the odor of amniotic fluid
A nurse is caring for a client in the first stage of labor who is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
Assist the client to breathe into a paper bag
A nurse is caring for a client who @ 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's BP 82/52. Which of the following nursing interventions should the nurse perform?
Assist the client to turn onto her side
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
BP 80/56
A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?
Breech
A nurse midwife is examine a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?
Cervical dilation
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?
Change the client's position
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not". Which of the following should the nurse recognize as a sign of true labor?
Changes in the cervix
A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?
Check the cervix prior to analgesic administration
A nurse is admitting a client who is at 38 weeks gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?
Continuous contraction lasting 2 min
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?
Contractions lasting longer than 90 seconds
A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
Contractions that last for 60 sec each with 3 min rest between contractions
A nurse on the labor and delivery unit is caring for a pt who is having induction of labor with oxytocin administers through a secondary IV line. Uterine contractions occur q2min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and the return to baseline after the contraction is over. Which of the following actions should the nurse take?
Discontinue the infusion fo the IV oxytocin
A nurse is caring for a client who had a vaginal delivery 2 h ago. Which of the following actions should the nurse anticipate in the care of this client?
Document fundal height Observe the lochia during palpation of fundus Determine whether the funds is midline Admin methylergonovine maleate if uterus is boggy
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following should the nurse implement?
Encourage the client to empty her bladder q2h
A nurse is caring for a client who gave birth 2 h ago. The nurse notes that the client's BP 60/50. Which of the following actions should the nurse take first?
Evaluate the firmness of the uterus
A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include?
Fetal breathing Fetal motion Amniotic fluid volume
A nurse on the l&d unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
Fetal position is persistent occiput posterior
A nurse is caring for a client who is 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
Frank breech
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?
Have the client pant during the next contractions
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
Hypotension
A nurse is a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is schedule stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following?
Location of the placenta
A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?
Massage the client's funds to promote contractions
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
Masses the client's back
A nurse is caring for a client who is gravid 3, para 2, and is in active labor. The fetal head is a 3+ station after a vaginal examination. Which of the following actions should the nurse take?
Observe for crowning
A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?
Obtain a 30 min electronic fetal monitoring EFM strip prior to induction
A nurse is caring for a client who is having a non stress test performed. The fetal heart rate (FHR) is 130-150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?
Offer the client a snack of orange juice and crackers
A nurse is caring for a client who is in labor and has epidural anesthesia block. The client's BP 80/40 and fetal HR 140/min. Which of the following is the priority nursing action?
Place the client in a lateral position
A nurse in the L&D unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal HR behind to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
Place the client in lateral position
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?
Position the client on her side
A nurse on labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and frequency of 3 min. The nurse obtains the following VS: fetal HR 130/min, maternal HR 128/min, and maternal BP 92/54. Which of the following is the priority action fro the nurse to take?
Position the client with one hip elevated
A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?
Postpartum hemorrhage
A nurse is assessing a client who is 12 h postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse?
RR @ 10/min
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
Respiratory rate @ 16/min
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the funds of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?
Right upper
A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make?
The is no evidence of uteroplacental insufficiency
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
The lowermost portion of the fetus is at level of the ischial spines
A nurse on the l&d unit is caring for a client following a vaginal exam by the provider which is document as: -1. Which of the following interpretations of this finding should the nurse make?
The presenting part is 1 cm above the ischial spines
A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal motor tracing shows late decelerations. Which of the following actions should the nurse take first?
Turn the client onto her side
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indiction which of the following?
Uteroplacental insufficiency
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
Variable decelerations
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
Variable decelerations are due to umbilical cord compression
A nurse is the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make?
You should try to pant as the delivery proceeds
A nurse is assisting with care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering?
vitamin K inj Hep B Antibiotic ointment to both eyes