PNE 136 Chapter 10
A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement?
"Anxiety can speed up the labor process."
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?
Assess fetal heart rate for fetal safety.
A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?
Check the fetal heart rate.
It is most likely that the practitioner would consider performing an amnioinfusion if the EFM tracing shows which of the following?
deep variable decelerations more than 60 bpm below the baseline with every contraction
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?
10:30 a.m.
Which documentation in the health record is most correct for the third stage of labor?
Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.
In the labor and delivery unit, which is the best way to prevent the spread of infection?
Complete hand hygiene
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?
Placing a wedge under the hips
As a woman enters the second stage of labor, which would the nurse expect to assess?
feelings of being frightened by the change in contractions
The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?
The client who is very restless and is moving around in the bed
At which time does the nurse anticipate that the primigravid client, G1P0, will need the most pain relief measures?
active phase (late) of the first stage of labor
When assessing a client in labor, the nurse observes that the fetal heart rate (FHR) gradually falls from 150 bpm to 132 bpm during the contraction and returns to baseline at the end of the contractions. The nurse interprets this finding as associated with which possible condition?
fetal head compression
The obstetric nurse is monitoring a client during the third stage of labor. What change in status should the nurse prioritize and report?
sudden chest pain
The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data?
"The client has saturated three sanitary napkins in the past 4 hours."
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?
Help the woman change positions
The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data?
a urine dipstick test to check for protein
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:
baseline FHR
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?
cervical dilation (dilatation) of 2 cm or more
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? You Selected:
cervical dilation (dilatation) of 2 cm or more
Which intervention would be least effective in caring for a clinet who is in the active phase of labor?
encouraging the client to ambulate
A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritized at this time?
ensure cervix fully dilated
A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?
fetal back
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?
fetal heart rate declining late with contractions and remaining depressed
A client comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is in which of the following stages of labor?
second stage
While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?
tachycardia and a falling blood pressure
Question 6 See full question1m 22sReport this Question Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide?
"It is important to try to urinate every 2 hours because you might not feel the urge."
The client may spend the latent phase of the first stage of labor at home unless which occurs
The client experiences a rupture of membranes
A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?
sudden gush of dark blood from the vagina
Which client statements indicate to the nurse that the client is entering the second stage of labor? Select all that apply.
*"I feel a lot of pressure." *"I feel a burning between my legs." *"I think the baby is coming." *"I need to have a bowel movement."
A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response?
A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently.
Which nursing action is applied throughout all stages of labor?
Do not allow the client to lay flat on her back for long periods.
The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?
Intermittent fetal heart rate auscultation
The nurse notes that the client has a moderate amount of bleeding after birth. Which instruction is anticipated to control bleeding?
Put the newborn to the breast to suck.
The client may spend the latent phase of the first stage of labor at home unless which occurs?
The client experiences a rupture of membranes
A client is admitted to the labor and delivery unit. Upon examination, the client is found to be dilated 3 cm. The nurse notes that the client is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this client?
latent phase
A client who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed?
placenta previa
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in?
Inform the RN that your client may have ruptured membranes.
A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate?
Notify the health care provider about possible meconium.
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?
The uterus contracts and squeezes the cord against the fetus.
The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time?
reposition the client on either side
A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique?
"Inhale through your nose and exhale through pursed lips."
Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide?
"It is important to try to urinate every 2 hours because you might not feel the urge."
The client reports having a rupture of membranes that occurred 24 hours ago. When assessing the client, which data is most pertinent? Select all that apply.
*Your temperature is 38.3°C (101°F). *I am having green-tinged fluid discharge. *I am having contractions which are 5 minutes apart. *The fetal monitor states that the fetal heart rate is 186 beats/min.
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman.
The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the LPN, is completed first?
Assess if the bladder is distended
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
Turn her or ask her to turn to her side.
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?
Vaginal examination
At what time is the laboring client encouraged to push?
When the cervix is fully dilated
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes?
a positive nitrazine test
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
every 15 minutes
