Maternal-Neonatal Nursing - Intrapartum Period

A client who is 5 cm dilated reports that she has the urge to push. Which is the appropriate response by the nurse? Encourage the client to push with the next contraction. Administer additional pain medication. Have client blow out breath to keep from pushing. Prepare the client for a cesarean section.

Have client blow out breath to keep from pushing.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Place the client in a Trendelenburg position. Administer oxytocin intravenously. Ask the client to begin pushing. Cover the cord with sterile towels.

Place the client in a Trendelenburg position.

In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia variable decelerations fetal heart rate accelerations late decelerations

fetal heart rate accelerations

The nurse is caring for a client who was admitted to the labor and birth department in preterm labor at 30 weeks' gestation. The nurse anticipates which medication will be given to help manage preterm labor? terbutaline indomethacin prostaglandin betamethasone

terbutaline Terbutaline reduces the frequency and intensity of uterine contractions by stimulating B2 receptors in the uterine smooth muscle. It is the drug of choice to inhibit labor. Indomethacin is an anti-inflammatory. Prostaglandins would induce cramping. Betamethasone, a synthetic corticosteroid, is administered to the mother to stimulate fetal pulmonary surfactant.

What actions does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply. assigning the Apgar scores administering oxytocin assisting with perineal repairs drying the newborn initiating skin to skin care taking newborn vital signs

assigning the Apgar scores drying the newborn initiating skin to skin care taking newborn vital signs

What assessment findings indicate that the multiparous client is in the transitional phase of the first stage of labor? Select all that apply. cervix dilated to 8 cm cervix effaced at 80% contractions occurring every 5-10 minutes and last approximately 60 seconds fetal presenting part at the -1 station contractions hard by palpation

cervix dilated to 8 cm cervix effaced at 80% contractions hard by palpation

The nurse is caring for a client in labor who has requested epidural anesthesia. Which will the nurse include in the client's plan of care? Select all that apply. infusing fluid bolus prior to epidural anesthesia monitoring blood pressure every 4 hours applying continuous external fetal heart monitoring applying oximetry during insertion of epidural anesthesia maintaining client in a Fowler's position after epidural insertion

infusing fluid bolus prior to epidural anesthesia applying continuous external fetal heart monitoring applying oximetry during insertion of epidural anesthesia

What assessment data of a laboring woman would require further intervention by the nurse? fetal heart rate (FHR) 150 beats/minute maternal heart rate 125 beats/minute temperature of 99.1° F (37.27° C) moderate contractions 3 minutes apart

maternal heart rate 125 beats/minute

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem? congenital anomalies pulmonary hypertension meconium aspiration syndrome respiratory distress syndrome

respiratory distress syndrome

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason? to prevent Rh-positive sensitization with the next pregnancy to provide active antibody protection for this pregnancy to decrease the amount of Rh-negative sensitization for the next pregnancy to destroy fetal Rh-positive cells during the next pregnancy

to prevent Rh-positive sensitization with the next pregnancy

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness

fetal heart rate

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? an increased sense of rectal pressure a decrease in intensity of contractions an increase in fetal heart rate variability episodes of nausea and vomiting

an increased sense of rectal pressure

A client is receiving oxytocin to induce labor. Which assessment findings indicate common adverse reactions? Select all that apply. blood pressure increased from baseline uterine tetany jaundice heart rate decreased from baseline variable decelerations

blood pressure increased from baseline uterine tetany variable decelerations

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? human resource director, so she can arrange vacation time for the staff physician, so he can provide education about HELLP syndrome social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff chaplain, because his educational background includes strategies for handling grief

chaplain, because his educational background includes strategies for handling grief

For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with moderate variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for which problem? exhaustion. chills and fever. fluid overload. meconium-stained fluid.

exhaustion

A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time? placing the client in bed to begin fetal monitoring preparing for immediate delivery checking for ruptured membranes providing comfort measures

preparing for immediate delivery

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking gingko biloba to help manage her blood sugars. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication? medication interactions hypertensive crisis oversedation prolonged bleeding

prolonged bleeding

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions? Position to left lateral, O2 per nonrebreather mask at 10 L. Position to knee-chest, increase IV fluids. Give orange juice, vibroacoustic stimulation. Administer terbutaline, turn off oxytocin infusion.

Position to left lateral, O2 per nonrebreather mask at 10 L.

A gravida 3 para 1 laboring client is 9 cm dilated and is changing position frequently to cope with the intensity of the contractions. The client's partner has gone to the cafeteria to take a break. The client tells the nurse that she is tired but is afraid of being left alone and that her partner will miss the birth. Which of the following is the nurse's most appropriate action? Tell the client that someone will try to find her partner. Return to the nurse's station to phone the health care provider because birth is imminent. Tell the client not to worry because the birth likely won't happen for another 4-5 hours. Use the call bell to ask another nurse for help locating the client's partner.

Use the call bell to ask another nurse for help locating the client's partner.

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? Notify the physicians and explain that they need to teach their clients before inducing labor. Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Report the physicians for providing inferior care. Initiate a protocol order that allows the nurse to administer promethazine before administering oxytocin.

Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction.

A client who has abruptio placentae exhibits cyanosis in the earlobes, capillary filling time >3 seconds, and reports "heartburn." Which is the best nursing intervention? Notify the healthcare provider immediately. Assess for vaginal bleeding. Increase the temperature of the room and provide warmed blankets. Elevate the head of the bed.

Notify the healthcare provider immediately.

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia? abnormally long uterine contractions abnormally strong uterine contractions excessively frequent contractions, with rapid fetal movement excessive fetal activity and fetal tachycardia

excessive fetal activity and fetal tachycardia

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? excitement loss of control numbness of the legs feelings of relief

loss of control

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse? total weight gain of 30 lb (13.6 kg) maternal age of 32 years blood pressure of 146/90 mm Hg treatment for syphilis at 15 weeks' gestation

blood pressure of 146/90 mm Hg

The nurse in the labor and birth area receives a telephone call from the emergency department announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby is coming ... Help!" The fetal skull is crowning. The nurse should obtain which information first? estimated date of birth amniotic fluid status gravida and parity prenatal history

estimated date of birth

A laboring client at 28 weeks gestation is in preterm labor. Her partner gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse? "Your partner seems to be coping just fine. She has managed very well today." "You and your partner have been through a lot with this pregnancy. Let's talk about this further." "You seem really stressed. Do you have any one to talk to about this?" "I know you are upset. However you need to put this in perspective for the sake of your partner and infant."

"You and your partner have been through a lot with this pregnancy. Let's talk about this further."

A laboring client on oxytocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings which of the following would be the best action for the nurse? Increase the oxytocin until uterine contractions exceed 80 seconds duration. Continue the oxytocin until uterine contractions are more frequent than every 2-3 minutes. Discontinue the oxytocin if the uterus does not relax between uterine contractions. Administer pain medicine for reports of increasing discomfort.

Discontinue the oxytocin if the uterus does not relax between uterine contractions.

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan? establishing rapport with the family acting as an advocate for the family attempting to correct any misinformation the family may have received recognizing the family as active participants in their care

recognizing the family as active participants in their care

The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply. IV hydration maternal position change oxygen administration epidural pain medication increased oxytocin infusions

IV hydration maternal position change oxygen administration

A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? The fetal scalp electrode is a small device that looks like a corkscrew. It's applied quickly after the baby's scalp is carefully palpated. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Inform the client that the fetal scalp electrode helps monitor fetal heart rate and assists with shortening the first stage of labor.

Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission.

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity? the moderate amount of bloody show the frequency of the uterine contractions the intact membranes the position of the baby

the intact membranes

A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: Give a 4-g bolus over 15 minutes, then decrease the rate to 2g/hour. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringer's on hand. What is the rate the nurse will set the pump to deliver the 2g maintenance dose? Record your answer using a whole number.

40

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: X-linked recessive and the disease will only occur if the baby is a boy. X-linked dominant and there is no likelihood of the baby having cystic fibrosis. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply. Increase the oxytocin infusion. Contact the healthcare provider. Administer oxygen to the client. Discontinue the external fetal heart monitor. Change the client's position.

Contact the healthcare provider. Administer oxygen to the client. Change the client's position.

The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first? Ask the anesthesiologist to increase epidural rate. Assist the client to push if she feels the need to do so. Encourage the client to breathe through the urge to push. Support family members in providing comfort measures.

Encourage the client to breathe through the urge to push.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? Be in a semi-Fowler's position or a position of comfort Flex the thighs onto the abdomen before bearing down. Exert downward pressure as if having a bowel movement. Hold the breath throughout the length of the contraction.

Hold the breath throughout the length of the contraction.

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first? Monitor the client's contraction pattern. Assess the fetal heart rate (FHR) for 1 full minute. Assess the client's temperature and pulse. Document the color of the amniotic fluid.

Assess the fetal heart rate (FHR) for 1 full minute.

A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The health care provider (HCP) has prescribed prostaglandin E2 gel for the client. Before administering prostaglandin E2 gel to the client, the nurse should perform which action first? Assess the frequency of uterine contractions. Place the client in a side-lying position. Determine whether the membranes have ruptured. Prepare the client for an amniotomy.

Assess the frequency of uterine contractions.

The health care provider (HCP) determines that outlet forceps are needed to assist in the birth of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse understands that the fetus's skull must be at what point before this procedure can take place? It is engaged past the inlet. It is at +1 station. It is visible at the perineal floor. It has reached the level of the ischial spines.

It is visible at the perineal floor.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? Place the mother in a knee-to-chest position. Palpate the cord for pulsations before notifying the physician. Attempt an external cephalic rotation. Restore circulation by stimulating the cord with a sterile glove.

Place the mother in a knee-to-chest position.

A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next? Perform a vaginal examination. Notify the health care provider (HCP) of the decelerations. Reposition the client and continue to evaluate the tracing. Administer oxygen via mask at 2 L/min.

Reposition the client and continue to evaluate the tracing.

A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful? Stand silently at the back of the room. Stand next to her at the side of the bed. Turn up the volume of the music playing in the room. Turn on the television as a focal point.

Stand next to her at the side of the bed.

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern? spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds late decelerations that occur with over 50% of contractions repetitive (at least 3) uncomplicated variable decelerations late decelerations with minimal variability

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds

A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement? time of fetal scalp electrode placement, name of the HCP who placed the electrode, and frequency of uterine contractions time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR) the name of the HCP who applied the electrode, Doppler transducer placement, and FHR the maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR

time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR)

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? active phase latent phase descent phase transitional phase TAKE ANOTHER QUIZ

transitional phase

A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client? client preference complexity of care requirements continuity: the nurse who cared for the client yesterday the most senior nurse on that morning shift

complexity of care requirements

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan." "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." "I'll insert a urinary catheter; then you won't need to get out of bed."

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."

A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response? "This is a routine assessment and your baby is fine." "The baby has had a bowel movement, indicating severe fetal distress." "The baby needs to be observed more closely." "The baby has had a bowel movement, indicating mild fetal distres

"The baby needs to be observed more closely."

A client is in the first stage of labor. She asks the nurse what the best physical position is to promote labor progression and efficient uterine contractions. What response by the nurse is most appropriate? "The best option at this stage is to ambulate." "Lying supine will conserve energy for the second stage of labor." "Any position, but ensure infrequent position changes if possible." "Lying on your side without the use of pillows."

"The best option at this stage is to ambulate."