Labor & Delivery Saunders NCLEX questions 80Qw/exp

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for throughout the client's labor? 1. Anxiety 2. Hemorrhage 3. Low self-esteem 4. Postpartum infection

4 Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Anxiety and low self-esteem are unrelated to physiological integrity.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate.

2 The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.

On March 10, 2015, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7, 2014. The nurse plans care based on which interpretation? 1. The client is possibly in preterm labor. 2. The fetus may not be viable at delivery. 3. The client may require labor augmentation. 4. The fetus is at high risk for shoulder dystocia.

1 According to Nägele's rule, subtracting 3 months and adding 7 days and 1 year to this client's LMP, her estimated date of delivery (EDD) would be April 14, 2015. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before her EDD, therefore possibly being in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation, so this would eliminate option 2. This fetus is approximately 4 weeks before term. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery, so option 4 can be eliminated. If this client truly is in labor, the health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation.

A nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1. Assess the fetal heart rate. 2. Check the client's temperature. 3. Change the pads under the client. 4. Check the client's respiratory rate.

1 After amniotomy or rupture of the membranes in the birth setting, the nurse immediately assesses the fetal heart rate for at least 1 minute to detect changes associated with prolapse or compression of the umbilical cord. The quantity, color, and odor of the amniotic fluid also are noted. The client's temperature should be assessed every 2 to 4 hours, and the nurse also would check the client's vital signs. The pads under the client should be changed regularly to promote comfort and reduce the moist environment that favors bacterial growth, but this is not the priority.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely.

1 Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

1 Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1. Measure fundal height. 2. Attach electronic fetal monitoring. 3. Prepare the client for a possible cesarean section. 4. Visually examine the perineum and vaginal opening.

1 The correct option is least appropriate because fundal height should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider (HCP) has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed? 1. Palpate the bladder at frequent intervals. 2. Encourage the woman to walk to progress the labor. 3. Assess the blood pressure frequently for hypertension. 4. Encourage the woman to assume a supine position after the epidural has been placed.

1 The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Hypotension, not hypertension, is a concern. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring

3 Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, however.

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure

4 A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

A nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? 1. Maternal fatigue 2. The passage of meconium 3. Coordinated uterine contractions 4. Progressive changes in the cervix

2 Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1. Contact the obstetrician. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist. 4. Prepare for imminent delivery of the fetus.

2 The FHR normally is 110 to 160 beats/min. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer, or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3 Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection.

he nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid.

3. The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal? 1. Light green, with no odor 2. Clear and dark amber-colored 3. Thick and white, with no odor 4. Pale straw-colored, with flecks of vernix

4 Amniotic fluid normally is pale straw-colored and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation

4 As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.

A nurse in the labor room is caring for a client who is 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. Based on this finding, which is the appropriate nursing action? 1. Contact the health care provider. 2. Place the mother in a Trendelenburg position. 3. Administer oxygen to the client by face mask. 4. Document the findings and continue to monitor fetal patterns.

4 Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1. Exhaustion 2. Valsalva maneuver 3. Involuntary grunting 4. Fear of losing control

4 Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate

4 Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted? 1. Back pain 2. Abdominal pain 3. Painful vaginal bleeding 4. Painless vaginal bleeding

4 The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of abruptio placentae.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding? 1. Back pain 2. Heavy vaginal bleeding 3. Increase in fundal height 4. Early deceleration on the fetal heart monitor

3 The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. Heavy vaginal bleeding, early deceleration on the fetal heart monitor, and back pain are not specific signs of concealed bleeding.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4 The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

The 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/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

1 A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

A nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing? 1. Hypotonic 2. Precipitate 3. Hypertonic 4. Preterm labor

1 Hypotonic labor contractions are short, irregular, weak, and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1 The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining options are incorrect regarding management of the client with abruptio placentae.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1 Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's position or prone position is not practical for this type of abdominal surgery.

The nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? 1. Increased urinary output 2. A fetal heart rate of 90 beats/min 3. Three contractions occurring within a 10-minute period 4. Adequate resting tone of the uterus palpated between contractions

2 A normal fetal heart rate is 110 to 160 beats/min. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies is which category of decelerations? 1. Episodic, late decelerations that indicate uteroplacental insufficiency 2. Periodic, early decelerations and indicative of fetal head compression 3. Periodic, variable decelerations and an indication of cord compression 4. Episodic, early decelerations that may be a result of maternal hypotension

2 An early deceleration is described as a visually apparent gradual decrease of the fetal heart rate with a gradual return to the FHR baseline. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described, so therefore eliminate option 3.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2 Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2 The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids are likely to be withheld at this time.

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin (Pitocin). 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

2 The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Applying oxygen, increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation. Contacting the client's primary support person(s) is not the priority action at this time.

A nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

2 When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to assess and document the fetal heart rate? 1. Hourly 2. Every 15 minutes 3. Every 30 minutes 4. Before each contraction

2 he second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1. Fentanyl 2. Morphine sulfate 3. Butorphanol tartrate 4. Meperidine hydrochloride (Demerol)

3 Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

A nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse should ensure that which is implemented before the beginning of the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside

3 Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin (Pitocin). There are no data in the question that indicate the need for complete bed rest or the need for antibiotics. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1. Bear down. 2. Hold her breath. 3. Breathe rapidly. 4. Push with each contraction.

3 During a precipitous labor, when the infant's head crowns, the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus.

A nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should assess that the amniotic fluid is normal if it has which characteristics? 1. Clear and dark amber color 2. Light green color with no odor 3. Thick white color with no odor 4. Straw-colored, with flecks of vernix

4 Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin watery consistency and may have a mild odor. The other options are not descriptions of normal amniotic fluid.

A nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse should document these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation

4 As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1. Chest pain 2. A rigid abdomen 3. A soft and boggy uterus 4. Complaints of severe abdominal pain

4 Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus would indicate that the muscle is not contracting.

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the most appropriate nursing action? 1. Sit the client in a high Fowler's position. 2. Call the pharmacy for a tocolytic medication. 3. Get intravenous (IV) therapy equipment and solution from the storage area. 4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

4 When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help accomplish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims position. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1. Prepare for delivery. 2. Administer a tocolytic. 3. Administer an opioid antagonist. 4. Turn the woman to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute.

4, 5, 6 Maternal hypotension results in decreased placental perfusion, so the focus of nursing care would be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, so option 1 can be eliminated. Option 2 can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Option 3 can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age.

4, 5, 6 Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor

1 Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic dystocia usually occurs during the latent phase of labor, and contractions are painful, frequent, and usually uncoordinated. Precipitous labor is labor that lasts in its entirety for 3 hours or less. Preterm labor is the onset of labor after 20 weeks of gestation and before the thirty-seventh week of gestation.

A nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding the nurse should prepare for which appropriate nursing action? 1. Administering oxygen via face mask 2. Placing the mother in a supine position 3. Increasing the rate of the intravenous (IV) oxytocin (Pitocin) infusion 4. Documenting the findings and continuing to monitor the fetal patterns

1 Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Option 4 would delay necessary treatment.

A nurse is providing emergency measures to a client in labor who has been diagnosed 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 client problem is most appropriate to address at this time? 1. The client's fear 2. The client's fatigue 3. The client's inability to control the situation 4. The client's inability to cope with the situation

1 The mother is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. No data in the question support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience.

The nurse is developing a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Keep the room semi-dark. 2. Initiate seizure precautions. 3. Pad the side rails of the bed. 4. Avoid environmental stimulation. 5. Allow out-of-bed activity as tolerated.

1, 2, 3, 4 Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. Additionally, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the central nervous system and causing a seizure.

A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of the infusion needs to be decreased? 1. Increased urinary output 2. A fetal heart rate of 180 beats/min 3. Three contractions occurring in a 10-minute period 4. Adequate resting tone of the uterus palpated between contractions

2 A normal fetal heart rate is 120 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

2 Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1. Reposition the laboring woman to knee-chest. 2. Assess the vagina and cervix with a gloved hand. 3. Notify the health care provider of the need for an amnioinfusion. 4. Document the description of the fetal bradycardia in the nursing notes.

2 It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented so therefore option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

The goal for a woman with partial premature separation of the placenta is, "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, would indicate that this goal has been achieved? 1. No accelerations of FHR 2. Short-term variability present 3. Variable decelerations present 4. Fetal heart rate (FHR) of 170 to 180 beats/min

2 Reassuring signs in the fetal heart tracing include an FHR of 120 to 160 beats/min, accelerations of the FHR, no variable decelerations, and the presence of short-term variability. The short-term variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations would indicate cord compression.

A nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes and have a duration of 35 seconds. Using this information, what is the most appropriate action for the nurse to take? 1. Prepare for imminent delivery. 2. Continue to monitor the client. 3. Report the findings to the obstetrician. 4. Report the FHR to the anesthesiologist on call.

2 The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring. The FHR is normally 120 to 160 beats/min. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR.

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and would expect to note which prescribed treatment for this condition? 1. Increased hydration 2. Oxytocin (Pitocin) infusion 3. Administration of a tocolytic medication 4. Administration of a medication that will provide sedation

2 Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. Options 1, 3, and 4 identify therapeutic measures for a client with hypertonic dysfunction.

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood

3 In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which is documented in the client's record? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is completely dilated. 4. The client begins to expel clear vaginal fluid.

3 The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. The other options are not specific assessment findings of the second stage of labor.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? 1. Slow the intravenous (IV) rate. 2. Continue the oxytocin (Pitocin) drip. 3. Place the client in a high Fowler's position. 4. Administer oxygen at 8 to 10 L/min via face mask.

4 Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. The IV infusion should be increased not decreased so as to increase the maternal blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The woman's position should be lateral with legs raised to increase maternal blood volume and improve the maternal vascular system.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4 True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4 Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

A nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely.

1 Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1. Stop the oxytocin infusion. 2. Check the client's blood pressure. 3. Check the client for bladder distention. 4. Place the client in a side-lying position.

1 Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion.

A nurse is developing a plan of care for a client experiencing dystocia, and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? 1. Monitoring fetal status 2. Providing comfort measures 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

1 The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.

The purpose of a vaginal examination is to specifically assess the status of which findings? Select all that apply. 1. Station 2. Dilation 3. Effacement 4. Bloody show 5. Contraction effort

1, 2, 3 The vaginal examination for a client in labor specifically determines effacement 0 to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation. Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1. Hematuria 2. Prolonged clotting times 3. Increased platelet count 4. Swelling of the calf of one leg 5. Petechiae, oozing from injection sites, and hematuria

1, 2, 5 Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.

3 Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? 1. Assess for signs and symptoms of labor. 2. Assess the client's temperature every 2 hours. 3. Schedule a daily ultrasound to assess fetal movement. 4. Schedule a non-stress test every 4 hours to assess fetal well-being.

1 As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A non-stress test may be done, but not every 4 hours.

A nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action? 1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. 2. Turn the client on her back and administer oxygen by face mask at 8 to 10 L/min. 3. Turn the client on her side and administer oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client on her back and administer oxygen by nasal cannula at 2 to 4 L/min.

1 If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To facilitate oxygen to the mother and her fetus, the client is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1. Perform an abdominal prep on the client. 2. Prepare the delivery room for a vaginal delivery. 3. Explain to the client why a cesarean delivery is necessary. 4. Call the health care provider to obtain a prescription for an antiviral medication.

3 Because neonatal infection of HSV is life threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal prep will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms not eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? 1. "It is the application of pressure to the sacrum to relieve a backache." 2. "It is a form of biofeedback to enhance bearing-down efforts during delivery." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."

3 Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis

3 Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine.

A pregnant 39-week-gestation gravida 1 para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B Streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? 1. Provide the client with instructions on how to push. 2. Prepare the labor room and the client for an imminent delivery. 3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4. Call the health care provider (HCP) to the labor and delivery unit to perform a delivery.

3 The client evidences progression toward delivery because the cervix is 6 cm dilated and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, her neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that intravenous antibiotic prophylaxis (IAP) be administered during labor. Providing the client with instructions in regard to pushing is not appropriate at a time when she does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore the HCP is not required for delivery at this time.

A nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1. Determine the fetal heart rate. 2. Provide peripads for the client. 3. Take the client's blood pressure. 4. Note the amount, color, and odor of the amniotic fluid.

1 When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 3 and 4 are also appropriate actions, but are not the initial actions in this situation. The nurse may assist the client in cleaning, changing clothing, and providing peripads but determining the fetal heart rate is the initial action.

During the intrapartum period, a nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean delivery. 4. Eliminate the need for analgesic administration.

2 A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1. "The medication will only affect you and your pain level when given during a contraction." 2. "The medication will provide the most optimal relief when it is given while your pain level is highest." 3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4. "You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

3 Intravenous medication should be administered slowly in small doses starting at the beginning of a contraction and carrying over for three to five contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of the medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. Options 1, 2, and 4 are incorrect information about the medication effects.

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which intervention is implemented before initiating the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside

3 Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. No data in the question indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate decelerations? 1. Prepare the client for a cesarean delivery. 2. Monitor the fetal heart rate every 30 minutes. 3. Encourage an upright or side-lying maternal position. 4. Increase the rate of the oxytocin (Pitocin) infusion every 10 minutes.

3 Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent fetal heart rate decelerations, without necessitating surgical intervention. Monitoring the fetal heart rate every 30 minutes will not prevent fetal heart rate decelerations. The nurse should discontinue an oxytocin infusion in the presence of fetal heart rate decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1. Noting whether the heart rate is greater than 140 beats/min 2. Placing the diaphragm of the Doppler on the mother's abdomen 3. Palpating the maternal radial pulse while listening to the fetal heart rate 4. Performing Leopold's maneuver first to determine the location of the fetal heart

3 The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the fetal heart rate (FHR) to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/min or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuver may help the examiner locate the position of the fetus but will not ensure a distinction between the two heart rates.

A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring

1, 2, 3, 5 In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

The nurse caring for a client in labor notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which best describes minimal variability? 1. FHR fluctuations are lasting more than 15 seconds. 2. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate. 3. FHR fluctuations are lasting more than 15 seconds. 4. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate.

1 The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into four different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/min. If the depth of the fluctuations is between 6 and 25 beats/min, moderate variability is present. Accelerations are defined as lasting more than 15 seconds and reaching at least 15 beats/min above the baseline. Decelerations, like accelerations, must last at least 15 seconds and go at least 15 beats/min below the baseline rate.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? 1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.

1 f a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is applied to the mother.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1. Forceps delivery 2. Schultz presentation 3. Hypotonic contractions 4. Weak bearing-down efforts

1 Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm3

2 A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.