MN Intrapartum-Fetal Heart Rate/NCLEX Exam 2

The nurse is assessing a client who states, "I think I'm in labor". Which of the following findings would positively confirm the client's belief? A. She is contracting q 5 minutes x 60 seconds. B. Her cervix has dilated from 2 to 4 cm C. Her membranes have ruptured D. The fetal head is engaged

B. Her cervix has dilated from 2 to 4 cm

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? A. 2 cm B. 4 cm C. 8 cm D. 10 cm

A. 2 cm

On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior, 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? A. Descent is progressing well B. Fetal head is not yet engaged C. Vaginal Delivery is imminent D. External rotation is complete

A. Descent is progressing well

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions to the delivery? A. Assists the woman into a squatting position B. Advises the woman to push only when she feels the urge C. Encourages the woman to push slowly and steadily D. Massages the perineum with mineral oil.

D. Massages the perineum with mineral oil.

The provision of support during labor has demonstrated that women experience a decrease in anxiety and a feeling of being in more control. In clinical situations, this has resulted in: a. A decrease in interventions b. Increased epidural rates c. Earlier admission to the hospital d. Improved gestational age

a. A decrease in interventions *Rationale:* a. Studies have shown that with a support person, be it a family member, friend, or professional such as a Doula or nurse, the patient experiences a decrease in anxiety and has a feeling of being in more control. This, in turn, results in a decrease in interventions, a significantly lower level of pain, and an enhanced overall maternal satisfaction. b. There is decreased use of pain medication with continuous labor support. c. There is no evidence that continuous labor support results in earlier admission to the hospital. d. There is no evidence that continuous labor support results in improved gestational age for the fetus.

As the nurse explains the purpose of the tocotransducer (Toco), which she places on the abdomen, she states that this monitoring device provides an accurate evaluation of which of the following? a. Uterine hypertonus b. Frequency of contractions c. Intensity of contractions d. Progress of labor

b. Frequency of contractions *Rationale:* a. Uterine tone is palpated or measured with an intrauterine pressure catheter (IUPC). b. A tocotransducer measures frequency and duration of uterine contractions. c. Contraction strength is palpated or measured with an intrauterine pressure catheter (IUPC). d. Progress of labor is evaluated with a sterile vaginal examination (SVE).

The labor patient you are caring for is ambulating in the hall. Her vaginal exam 1 hour ago indicated she was 4/70/-1 station. She tells you she has fluid running down her leg. Your priority nursing intervention is to: a. Assess the color, odor, and amount of fluid. b. Assist your patient to the bathroom. c. Assess the fetal heart rate. d. Call the care provider.

c. Assess the fetal heart rate. *Rationale:* a. Although assessing the color, odor, and amount of fluid is appropriate, the priority nursing action is to assess the FHR because of the risk of umbilical cord prolapse with rupture of membranes. b. The fluid is probably related to rupture of membranes rather than the patient needing to go to the bathroom to urinate. c. Assessing the fetal heart rate is the first priority because of the risk of umbilical cord prolapse with rupture of membranes. d. Although you may call the care provider, the priority nursing action is to assess the FHR because of the risk of umbilical cord prolapse with rupture of membranes.

You are caring for a woman in labor who is 6 cm dilated with a reassuring FHR pattern and regular strong UCs. The fetal heart rate (FHR) should be: a. Monitored continuously b. Monitored every 15 minutes c. Monitored every 30 minutes d. Monitored every 60 minutes

c. Monitored every 30 minutes *Rationale:* Assessment of fetal heart rate (FHR) during the active phase of labor with a reassuring FHR is indicated every 30 minutes.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks' gestation in her first pregnancy. She is worried about having her baby "too soon," and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks contractions

d. Braxton-Hicks contractions *Rationale:* a. Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the end of the 36th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor. b. Term labor occurs after 37 weeks' gestation. c. There is no indication in this scenario that this is back labor. d. Braxton-Hicks contractions are regular contractions occurring after the third month of pregnancy. They may be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

You are in the process of admitting a multiparous woman to labor and delivery from the triage area. One hour ago her vaginal exam was 4/70/0. While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to: a. Reassure the patient and rapidly complete the admission. b. Assist your patient to the bathroom to have a bowel movement. c. Assess the fetal heart rate and uterine contractions. d. Perform a vaginal exam.

d. Perform a vaginal exam. *Rationale:* a. Completing the admission paperwork is not a priority when birth may be imminent. b. The urge to have a bowel movement is probably related to fetal descent and complete dilation rather than the patient needing to have a bowel movement. c. Doing a vaginal exam is the first priority as birth may be imminent. d. Perform a vaginal exam to assess the progress of labor. The urge to have a bowel movement and feeling like pushing indicate that birth may be imminent.

When caring for a primiparous woman being evaluated for admission for labor, a key distinction between true versus false labor is: a. True labor contractions result in rupture of membranes, and with false labor, the membranes remain intact. b. True labor contractions result in increasing anxiety and discomfort, and false labor does not. c. True labor contractions are accompanied by loss of the mucus plug and bloody show, and with false labor there is no vaginal discharge. d. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

d. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes. *Rationale:* a. Rupture of membranes can occur prior to labor or during labor. b. A woman's response to labor may not be reflective of her status in labor but is influenced by expectations and emotional status. c. Loss of the mucus plug can occur prior to the onset of labor. d. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. A. Assess the fetal heart rate B. Infuse 1000 mL of ringer's lactate C. Place the woman in Trendelenburg position D. Monitor blood pressure every 5 minutes for 15 minutes E. Have the woman empty her bladder

A. Assess the fetal heart rate B. Infuse 1000 mL of ringer's lactate E. Have the woman empty her bladder

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select All That Apply. A. Bulging perineum B. Increased bloody show C. spontaneous rupture of membranes D. uncontrollable urge to push E. Inability to breathe through contractions

A. Bulging perineum B. increased bloody show D. uncontrollable urge to push

Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply. A. Engage in sexual intercourse B. Ingest evening primrose oil C. Perform yoga exercises D. Eat raw spinach E. Massage the breast and nipples

A. Engage in sexual intercourse B. Ingest evening primrose oil E. Massage the breast and nipples

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare provider, which of the following assessments should the nurse perform? Select all that apply. A. Fetal heart rate B. Contraction pattern C. UA D. Vital signs E. Biophysical Profile

A. Fetal heart rate B. Contraction pattern D. Vital signs

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. A. Lengthening of the umbilical cord B. Fetal heart assessment after each contraction C. Uterus rising in the abdomen and feeling globular D. Rapid cervical dilation to 10 cm E. Maternal complaints of intense rectal pressure

A. Lengthening of the umbilical cord C. Uterus rising in the abdomen and feeling globular

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minutes. What should the nurse doe? A. Provide caring labor support B. Administer oxygen via face mask C. Change the client's position D. Speed up the client's intravenous

A. Provide caring labor support *Rationale:* The tracing is normal and no intervention is needed

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station -2. Which of the following has the nurse palpated? A. Thin cervix B. bulging fetal membranes C. head a the pelvic outlet D. Closed cervix

A. Thin cervix

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? A. Sacral promontory B. Ischial Spines C. Cervix D. Symphysis Pubis

B. Ischial Spines *Rationale:* Palpating the sacral promontory and symphysis pubis assesses the obstetric conjugate, not the fetal station Palpating the cervix assesses dilation and effacement, not station

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? A. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions B. Baseline of 140-150 with decelerations to 100 that mirror each of the contractions C. Baseline of 140-142 with decelerations to 120 that return to baseline after the end of the contractions D. Baseline of 140-142 with no obvious decelerations or accelerations

B. Baseline of 140-150 with decelerations to 100 that mirror each of the contractions

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must precede this assessment? A. Place the client in the lateral recumbent position. B. Carefully analyze the baseline data on the monitor tracing C.Administer oxygen to the mother via face mask. D.Ask the mother to indicate when she feels fetal movement

B. Carefully analyze the baseline data on the monitor tracing

Between contraction, a client in the active phase of labor states, "Not only do these contractions hurt me, but what are they doing to my baby? I am so scared and I cant stop thinking about how my baby might be hurting too". The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary HCP to order which of the following labor pain-relieving methods? A. Epidural B. Nitrous Oxide C. Narcotic analgesic D. Spinal

B. Nitrous Oxide

In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? A. Lying in the lithotomy position B. Performing effleurage C. Practicing kegel exercises D. Pushing with each contraction

B. Performing effleurage

A G1 P0, 8 cm dilated, is to receive pain medication. The HCP has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesic. Which of the following medications would the nurse expect to be ordered in conjuction with the analgesic medication? A. Seconal (secobarbital) B. Phenergan (promethazine) C. Stadol (butorphanol) D. Tylenol (acetaminophen)

B. Phenergan (promethazine)

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? A. Report the findings to the woman's HCP B. Immediately assess the woman's pulse and BP C. Continue to provide encouragement during each contraction D. Place the client on her side with oxygen via face mask

C. Continue to provide encouragement during each contraction

A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? A. Variable decelerations B. Late decelerations C. Decreased variability D. Transient accelerations

C. Decreased variability

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and+1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: A. 9 cm dilated, 70% effaced, and+2 station. B. 9 cm dilated, 80% effaced, and +3 station. C. 10 cm dilated, 90% effaced, and+4 station. D. 10 cm dilated, 100% effaced, and+5 station

D. 10 cm dilated, 100% effaced, and+5 station

A laboring woman and two men enter the labor suite. One of the men states, "We and our surrogate are here for our baby's delivery. Where should we go?" Which of the following responses by the nurse would be appropriate? A. Congratulate the surrogate on the gift she is giving the gay couple B. Remind the men that labor and delivery experience is very stressful C. Remind the men that the woman is the baby's mother D. Ask the laboring woman whom she would like to be with her during labor.

D. Ask the laboring woman whom she would like to be with her during labor.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing the first level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? A. Encourage the woman to have an epidural B. Encourage the woman to accept IV analgesia C. Encourage the woman to change her position D. Encourage the woman to perform the next level breathing

D. Encourage the woman to perform the next level breathing

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse perform during the next contraction? A. Encourage the woman to push B. Provide firm fundal pressure C. Move the client into a squat D. Monitor for signs of rectal pressure

D. Monitor for signs of rectal pressure

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgement should be questioned if the fetal presenting part is which of the following? A. Sacrum B. Occiput C. Mentum D. Scapula

D. Scapula

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? A. Alternatively panting and blowing B. Rapid, deep breathing C. Grunting and pushing with contractions D. Slow chest breathing

D. Slow chest breathing

The nurse uses the external electronic fetal heart monitor to evaluate fetal status. The fetal heart tracing shows accelerations. Accelerations in the fetal heart are: a. Associated with fetal well-being and oxygenation b. An indication of potential fetal intolerance to labor c. Never associated with the uterine contraction pattern d. A reason to notify the care provider

a. Associated with fetal well-being and oxygenation *Rationale:* a. Accelerations are a sign of fetal well-being. b. Accelerations are a sign of fetal well-being and are reassuring. c. Accelerations may or may not be associated with uterine contractions. d. Accelerations are reassuring, and there is no need to notify the care provider.

After assessing the FHR tracing shown below, which of the following interventions should the nurse perform? a. Turn the woman on her side. b. Administer oxygen by nasal cannula. c. Encourage the patient to push with each contraction. d. Provide the patient with caring labor support.

a. Turn the woman on her side. *Rationale:* a. The woman's position should be changed. The side-lying position is the best. b. If a laboring patient needs oxygen, it should be administered via face mask. c. There is no indication in the scenario that the patient is fully dilated. d. The nurse should not wait to intervene. He or she should intervene as quickly as possible in order to reverse the problem.

A nurse is preparing to monitor a patient who is to receive an amnioinfusion. Which of the following actions should the nurse make at this time? a. Attach the patient to an electronic blood pressure cuff. b. Assist in insertion of an internal uterine pressure catheter. c. Attach the patient to an oxygen saturation monitor. d. Perform an amniotic fluid Nitrazine test.

b. Assist in insertion of an internal uterine pressure catheter. *Rationale:* a. The patient's blood pressure will need to be monitored, but a manual cuff is sufficient. b. There is a possibility of uterine rupture during an amnioinfusion. An internal pressure transducer, therefore, must be inserted to monitor the patient's intrauterine pressures. c. The woman's oxygen saturation levels need not be monitored during the amnioinfusion. d. Because the woman's membranes are already ruptured, there is no need for a Nitrazine test to be performed.

In caring for a primiparous woman in labor, one of the factors to evaluate is uterine activity. This is referred to as the __________ of labor. a. Passenger b. Passage c. Powers d. Psyche

c. Powers *Rationale:* a. The passenger refers to the fetus. b. The passage refers to the pelvis and birth canal. c. Powers refer to the contractions. d. Psyche refers to the response of a woman to labor.

Which statement correctly describes the nurse's responsibility related to electronic fetal monitoring? a. Teach the woman and her family about the monitoring equipment and discuss any questions they have. b. Report abnormal findings to the care provider before initiating corrective actions. c. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place. d. Document the frequency, duration, and intensity of contractions measured by the external device.

a. Teach the woman and her family about the monitoring equipment and discuss any questions they have. *Rationale:* a. Teaching is an essential part of the nurse's role. b. Corrective measures for a non-reassuring fetal heart rate are done before notifying a provider. c. The support person can help to provide comfort measures for women in labor. d. Only an IUPC will measure the intensity of uterine contractions.

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select All That Apply. A. Give the woman a back rub B. Assist the woman with her breathing C. Assess the fetal heart rate D. Check the woman's blood pressure E. Regulate the woman's IV infusion rate

A. Give the woman a back rub B. Assist the woman with her breathing

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? A. Inform the mother that the rate is normal B. Reassess in 5 minutes to verify the results C. Immediately report the rate to the healthcare provider D. Place the client on her left side and apply oxygen by face mask

A. Inform the mother that the rate is normal

The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? A. Spontaneous fetal movement B. Fetal heart acceleration C. Increase in fetal heart variability D. Resolution of late decelerations

B. Fetal heart acceleration

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? A. Assess the blood pressure B. Have the woman breathe into a bag C. Turn the woman onto her side D. Check the fetal heart rate

B. Have the woman breathe into a bag

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? A. Decreased pulse rate B. Hypertension C. Hyperthermia D. Decreased respiratory rate

B. Hypertension

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following side effects? A. Paresthesias in her feet and legs B. Drop in blood pressure C. Increase in Central Venous pressure D. Fetal heart accelerations

B. Drop in blood pressure

A woman is considered in active labor when: A. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. B. Cervical dilation progresses to 3 cm with effacement of 30, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. C. Cervical dilation progresses to 8 cm with effacement of 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. D. Cervical dilation progresses to 10 cm with effacement of 90%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.

A. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. *Rationale:* a. Characteristics of this phase are the cervix dilates, on an average, 1.2 cm/hr for primiparous women and 1.5 cm/hr for multiparous women. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%. Fetal descent continues and contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds, and discomfort increases. b. Cervical dilation progresses to 3 cm with effacement of 30, indicating the early or latent phase of labor. c. Cervical dilation progresses to 8 cm with effacement of 80%, indicating the transition phase of labor. d. Cervical dilation of 10 cm with effacement is the end of the first stage of labor.

The labor and delivery nurse performs Leopold Maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? A. Left Occipital Anterior B. Left Sacral Posterior C. Right Mentum Anterior D. Right Sacral Posterior

A. Left occipital anterior

The childbirth education nurse is evaluating the learning of four women, 38-40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. A. The client who says "If I feel a pain in my back and lower abdomen every 5 minutes" B. The client who says " When I feel a gush of clear fluid from my vagina" C. The client who says "When I go to the bathroom and see the mucous plug on the toilet tissue" D. The client who says "If I ever notice a greenish discharge from my vagina" E. The client who says "When I have felt cramping in my abdomen for 4 hours or more"

A. The client who says "If I feel a pain in my back and lower abdomen every 5 minutes" B. The client who says "When I feel a gush of clear fluid from my vagina" D. The client who says "If I ever notice a greenish discharge from my vagina"

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? A. The relationship between the decelerations and the labor contractions B. The maternal blood pressure C. The gestational age of the fetus D. The placement of the fetal heart electrode in relation to the fetal position

A. The relationship between the deceleration and the labor contractions

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead the nurse to that conclusion? A. The woman talks and laughs during contractions B. The woman complains about severe back labor C. The woman performs effleurage during a contraction D. The woman asks to go to the bathroom to defecate

A. The woman talks and laughs during contractions

A pregnant woman is discussing possible delivery options with a labor nurse. Which of the following client responses indicates that the woman understood the information? Select all that apply. A. When the client states "I am glad that deliveries can take place in a variety of places, including in the labor bed" B. When the client says "I heard that for doctors to deliver babies safely, it is essential that I lie on my back with my legs up C. When the client states "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees" D. When the client says "During difficult deliveries it is sometimes necessary to put a woman's feet up in stirrups" E. When the client states "I heard that midwives often deliver their patients either in the side-lying or squatting position"

A. When the client states "I am glad that deliveries can take place in a variety of places, including in the labor bed" C. When the client states "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees" D. When the client says "During difficult deliveries it is sometimes necessary to put a woman's feet up in stirrups" E. When the client states "I heard that midwives often deliver their patients either in the side-lying or squatting position"

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? A. fetal position B. Lithotomy position C. Trendelenburg position D. Lateral recumbent position

A. fetal position

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with they physical assessment? Select all that apply. A. weight gain B. ethnicity and religion C. Age D. Type of insurance E. Gravidity and parity

A. weight gain B. ethnicity and religion C. age E. gravidity and parity

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. A.After vaginal exams. B.Before administration of analgesics. C.Periodically at the end of a contraction. D.Every ten minutes. E.Before ambulating

A.After vaginal exams. B.Before administration of analgesics. C.Periodically at the end of a contraction. E.Before ambulating

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? A. Offer the client the bedpan B. Evaluate the progress of labor C. Notify the physician D. Encourage the patient to push

B. Evaluate the progress of labor *Rationale:* Evaluate to see if she is in the 2nd stage of labor, if so, notify the physician next. If not, continue to push.

A client is in the 2nd stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? A. Awaken the woman and remind her to push B. Cover the woman's perineum with a sheet C. Assess the woman's blood pressure and pulse D. Administer oxygen to the woman via face mask

B. Cover the woman's perineum with a sheet

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? A. Assess the fetal heart rate between contractions every 60 minutes B. Encourage the woman to grunt during contractions C. Assess the pulse and respirations of the mother every 5 minutes D. Position the woman on her back with her knees on her chest

B. Encourage the woman to grunt during contractions

A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? A. Assess the woman's temp B. Place a wedge under the woman's side C. Place a blanket roll under the woman's feet D. Assess the woman's pedal pulses

B. Place a wedge under the woman's side

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and exited at that time. During the past 10 minutes she becomes serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? A. The client had poor childbirth education prior to labor B. The client is exhibiting an expected behavior for labor C. The client is becoming hypoxic and hypercapnic D. The client needs her alpha-fetoprotein levels checked

B. The client is exhibiting an expected behavior for labor

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? A. The woman has an internal laceration B. The woman is about to deliver the placenta C. The woman has an atonic uterus D. The woman is ready to expel the cord bloods

B. The woman is about to deliver the placenta

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding". Which of the following responses should the nurse make first? A. Does it burn when you void? B. You sound frightened. C. That is just the mucous plug D. How much blood is there

B. You sound frightened *Rationale:* Acknowledging the patient's concerns

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? A ."I am so excited to be in labor." B."I can't stand this pain any longer!" C."I need ice chips because I'm so hot." D."I have to push the baby out right now!"

B."I can't stand this pain any longer!"

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? A.The fetus has become engaged. B.The fetal head has entered the true pelvis. C.The fetal lie is horizontal. D.The fetus is in an extended attitude.

B.The fetal head has entered the true pelvis.

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min x30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner? A.The woman is high risk and should be placed on tocolytics. B.The woman is in early labor and could be sent home. C.The woman is high risk and could be induced. D.The woman is in active labor and should be admitted to the unit.

B.The woman is in early labor and could be sent home.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? A. Coach the woman to hold her breath while pushing 3-4 times with each contraction B. Administer oxygen via face mask at 8-10 liters per minute C. Delay pushing until the baby descends further and the mother has a strong urge to push D. Place the woman on her side and assess her oxygen saturation

C. Delay pushing until the baby descends further and the mother has a strong urge to push

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? A. Flexion B. Internal rotation C. Extension D. External rotation

C. Extension

A gravid client at term called the labor suite at 7:00 pm questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: A. At 5 pm, the contractions were about 5 minutes apart. Now they're about 7 minutes apart B. I took a walk at 5 pm, and now I talk through my contractions easier than I could then C. I took a shower about a half hour ago. The contractions hurt more than they did before. D. I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap

C. I took a shower about a half hour ago. The contractions hurt more than they did before.

The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? A. Mothers who are performing breathing exercises during labor refrain from yelling B. Breathing and relaxation exercises are less exhausting than crying and moaning C. Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle D. Childbirth education classes help to promote positive maternal-newborn bonding.

C. Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle

When performing Leopold Maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

C. Left lower quadrant

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select All that apply. A. Hypnotic suggestion B. Rhythmic chanting C. Muscle relaxation D. pelvic rocking E. abdominal massage

C. Muscle relaxation D. Pelvic rocking E. Abdominal massage

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? A. Mentum anterior. B. Sacrum posterior. C. Occiput posterior. D. Scapula anterior.

C. Occiput Posterior

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? A. Assist the mother with childbirth breathing B. Encourage mother to have an epidural C. Provide direct sacral pressure D. Move the woman to a hydrotherapy tub

C. Provide direct sacral pressure

The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? A. Alternatively pant and blow B. Take rhythmic, shallow breaths C. Push down with an open glottis D. Do slow chest breathing

C. Push down with an open glottis

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? A. Left upper quadrant B. Left lower quadrant C. Right upper quadrant D. Right lower quadrant

C. Right upper quadrant (fetus' back)

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? A. Epidurals do not work well when the pain level is above 5 B. I will contact the doctor to get an order for an epidural right away C. The baby is going to be born very soon. It is really too late for an epidural D. I will check the fetal heart rate. You can have an epidural if it is over 120.

C. The baby is going to be born very soon. It is really too late for an epidural

While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? A. The fetal position is transverse B. The fetal presentation is vertex C. The fetal lie is vertical D. The fetal attitude is flexed

C. The fetal lie is vertical Rationale: With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical. Fetal attitude is difficult to determine when performing Leopolds Maneuvers.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following would promote learning by the young women? A. Avoiding the discussion of uncomfortable procedures like vaginal exams and blood tests B. Focusing the discussion on baby care rather than on labor and delivery C. Utilizing visual aids like movies and posters during the classes D. Having the classes at a location other than high school to reduce their embarrassment

C. Utilizing visual aids like movies and posters during the classes

The nurse documents in a laboring woman's chart that the fetal heart rate is being "assessed via intermittent auscultation". To be consistent with this statement, the nurse, using a doppler electrode, should assess the fetal heart rate at which of the following times? A. After every contraction B. For 10 minutes every half hour C. Only during the peak of contractions D. For 1 minute immediately after contractions

D. For 1 minute immediately after contractions

The Apgar score consists of a rapid assessment of five physiological signs that indicate the physiological status of the newborn and includes: a. Apical pulse strength, respiratory rate, muscle flexion, reflex irritability, and color b. Heart rate, clarity of lungs, muscle tone, reflexes, and color c. Apical pulse strength, respiratory rate, muscle tone, reflex irritability, and color of extremities d. Heart rate, respiratory rate, muscle tone, reflex irritability, and color

D. Heart rate, respiratory rate, muscle tone, reflex irritability, and color *Rationale:* a. Heart rate, not apical pulse strength, is the criterion for Apgar scoring; muscle tone, not flexion, is assessed. b. Clarity of lungs and reflexes are not assessed as part of Apgar scoring. Neonatal lungs can be congested normally at birth, and reflexes are not assessed. Rather, reflex irritability is assessed, based on response to tactile stimulation. c. Heart rate, not apical pulse strength, is assessed along with respiratory rate, muscle tone, reflex irritability, and color of extremities. d. The Apgar score includes assessment of heart rate based on auscultation, respiratory rate based on observed movement of chest, muscle tone based on degree of flexion and movement of extremities, reflex irritability based on response to tactile stimulation, and color based on observation.

A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? A. The baby is in the breech position. B. The baby is in the horizontal lie. C. The baby's presenting part is engaged. D. The baby's chin is resting on its chest

D. The baby's chin is resting on its chest

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? A. The contractions are 5-20 minutes apart B. I saw a pink discharge on the toilet tissue when I went to the bathroom C. I have had cramping for the past 3-4 hours D. The contractions are about a minute long and I am unable to talk through them

D. The contractions are about a minute long and I am unable to talk through them

After analyzing an internal fetal monitoring tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? A. The fetus is becoming hypoxic B. The fetus is becoming alkalotic C. The fetus is in the middle of a sleep cycle D. The fetus has a healthy nervous system

D. The fetus has a healthy nervous system

A woman who states that she thinks she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? A. Leopold Maneuvers B. Fundal contractility C. Fetal heart assessment D. Vaginal examination

D. Vaginal examination

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? A. Oxygen saturation of 99% B. Hgb of 11 g/dL C. Serum glucose of 140 mg/dL D. pH of 7.30

D. pH of 7.30

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? A."The baby's head is engaged." B."The baby is floating." C."The baby is at the ischial spines." D."The baby is almost crowning."

D."The baby is almost crowning."

The perinatal nurse providing care to a laboring woman recognizes a category II, fetal heart rate tracing. The most appropriate initial action is to: a. Assist the laboring woman to a left lateral position b. Decrease the intravenous solution c. Request that the physician/certified nurse-midwife come to the hospital STAT d. Document the fetal heart rate and variability

a. Assist the laboring woman to a left lateral position *Rationale:* a. Because Category II fetal heart rate patterns could deteriorate, they constitute a risk indicator for fetal hypoxia, the nurse should change the woman's position to her side to increase oxygen flow to the baby. b. Because Category II fetal heart rate patterns could deteriorate, they constitute a risk indicator for fetal hypoxia, the nurse should increase, not decrease, the IV infusion to increase perfusion through the placenta. c. The scenario described does not require STAT intervention but continued assessment after intrauterine resuscitation interventions. d. Documentation of the FHR is important but not the most important action in this scenario.

The nurse knows that a FHR monitor printout indicates a Category III abnormal fetal heart rate pattern when: a. Baseline variability is minimal or absent with decelerations. b. FHR mirrors the uterine contractions. c. Occasional periodic accelerations occur. d. Baseline variability is 6 to 25 bpm with decelerations

a. Baseline variability is minimal or absent with decelerations. *Rationale:* a. Minimal or absent baseline variability may be an indication of fetal hypoxia. b. This answer describes early decelerations that are not an indication of fetal intolerance of labor. c. Periodic accelerations are a sign of fetal well-being.

A woman you are caring for in labor requests an epidural for pain relief in labor. Included in your preparation for epidural placement is a baseline set of vital signs. The most common vital sign to change after epidural placement: a. Blood pressure, hypotension b. Blood pressure, hypertension c. Pulse, tachycardia d. Pulse, bradycardia

a. Blood pressure, hypotension *Rationale:* Blood pressure, hypotension, as up to 40% of women may experience hypotension. Hypotension is defined as systolic BP <100 mm Hg or 20% decrease in BP from preanesthesia levels. Intravenous bolus is typically given to decrease the incidence of hypotension.

The mechanism of labor known as cardinal movements of labor are the positional changes that the fetus goes through to best navigate the birth process. These cardinal movements are: a. Engagement, Descent, Flexion, Extension, Internal rotation, External rotation, Expulsion b. Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion c. Engagement, Flexion, Internal rotation, Extension, External rotation, Descent, Expulsion d. Engagement, Flexion, Internal rotation, Extension, External rotation, Flexion, Expulsion

b. Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion *Rationale:* Engagement occurs when the greatest diameter of the fetal head passes through the pelvic inlet. Engagement can occur late in pregnancy or early in labor. Descent is the movement of the fetus through the birth canal during the first and second stages of labor. Flexion is when the chin of the fetus moves toward the fetal chest. Flexion occurs when the descending head meets resistance from maternal tissues. This movement results in the smallest fetal diameter to the maternal pelvic dimensions. It typically occurs early in labor. Internal rotation is the movement, the rotation of the fetal head, that aligns the long axis of the fetal head with the long axis of the maternal pelvis. It occurs mainly during the second stage of labor. Extension is the movement facilitated by resistance of the pelvic floor, causing the presenting part to pivot beneath the pubic symphysis and the head to be delivered. This occurs during the second stage of labor. External rotation is when the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis. Expulsion is the movement that occurs when the shoulders and remainder of the body are delivered.

The nurse is caring for a woman, G2 P1001, 40 weeks' gestation, in labor. A 12 P.M. assessment revealed: cervix 4 cm, 80% effaced, -3 station, and fetal heart 124 with moderate variability. 5 p.m. assessment: cervix 6 cm, 90% effaced, -3 station, and fetal heart 120 with minimal variability. 10 a.m. assessment: cervix 8 cm, 100% effaced, -3 station, and fetal heart 124 with absent variability. Based on the assessments, which of the following should the nurse conclude? a. Descent is progressing well. b. Woman is carrying a small-for-gestational age fetus. c. Baby is potentially acidotic. d. Woman should begin to push with the next contraction.

c. Baby is potentially acidotic. *Rationale:* a. The baby has not descended since admission. The station is still -3. b. The baby may be macrosomic. Because the baby is not descending, the baby may be too large to traverse through the pelvis. c. The variability is decreasing. This is an indication that the fetus is in distress. d. The woman is only 8 cm dilated. She should not begin to push until she has reached 10 cm dilation. Plus, the fetal station is still -3.

Early decelerations are probably caused by: a. Decreased maternal-fetal exchange b. Umbilical cord occlusion c. Momentary increase in intracranial pressure due to head compression d. Compression of umbilical cord

c. Momentary increase in intracranial pressure due to head compression *Rationale:* a. Decreased maternal-fetal exchange results in late decelerations. b. Umbilical cord occlusion results in variable deceleration or bradycardia. c. Early decelerations are related to increased intracranial pressure due to head compression. d. Compression of the umbilical cord results in variable decelerations.