SAUNDERS Intrapartum

The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply. 1.The membranes are ruptured. 2.The fetus is in the breech position. 3.Lesions are present on the perineum. 4.The fetus is not settled into the pelvis. 5.The pregnancy is at 41 weeks' gestation.

2 3 4 Induction of labor is contraindicated if the woman has placenta previa, umbilical cord prolapse, abnormal fetal presentation, a high station of the fetus or a small maternal pelvis, active herpes infection in the birth canal, abnormal size or structure of the mother's pelvis, and a previous classic (vertical) cesarean incision.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse? 1.Deep tendon reflexes of 2+ 2.Respirations of 10 breaths per minute 3.Fetal heart tones of 116 beats per minute 4.Urinary output of 20 mL since the last check

2. Respirations of 10 breaths per minute Rationale: Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication needs to be reassessed. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. Urinary output of 20 mL of urine in 30 minutes is adequate since the acceptable criterion is greater than 30 mL/hr.

The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, which nursing action can the nurse implement that will promote the birth of the placenta? 1.Increasing the IV infusion rate 2.Keeping the client in the lithotomy position 3.Adding oxytocin to the intravenous (IV) infusion 4.Putting the baby to the mother's breast and letting the baby suck

4 Nipple stimulation causes the posterior pituitary of the woman to secrete natural oxytocin, which causes the uterine muscles to contract. This is a method that can be an independent action of the nurse. Options 1 and 3 are not appropriate and require a primary health care provider's prescription. Option 2 will not assist in the contraction of the uterus.

Which would be the appropriate method to use to deliver the placenta after a precipitate delivery? 1.Wait for approximately 30 minutes and then pull it out. 2.Wrap the cord around a sponge stick and tug upward. 3.Gently guide the placenta out after a spontaneous separation. 4.The nurse's scope of practice does not include delivering the placenta.

Gently guide the placenta out after a spontaneous separation. The placenta is allowed to separate spontaneously, and then it is very gently guided out. The placenta is attached to the uterine wall, and if it is pulled hard or left in the uterus, hemorrhage would occur. There may be times when it is necessary for the nurse to assist in the delivery of the placenta

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 per minute. Which nursing action is appropriate? 1.Notify the registered nurse (RN). 2.Continue monitoring the fetal heart rate. 3.Encourage the client to continue pushing with each contraction. 4.Encourage the client's coach to continue encouraging breathing techniques.

1 A normal fetal heart rate is 110 to 160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the RN needs to be notified. Options 2, 3, and 4 are not appropriate nursing actions in this situation.

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1.Lengthening of umbilical cord 2.Sudden trickle or spurt of blood 3.Fundus is boggy following separation 4.Change from globular to discoid shape 5.Fetal membranes are seen at the introitus

1 2 5 Rationale: As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, a sudden trickle or spurt of blood appears and fetal membranes may appear at the introitus. The fundus changes from discoid to globular shape. The fundus should not become boggy.

The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines? 1.Longitudinal lie 2.Minus (-) 1 station 3.Vertex presentation 4.Right occiput anterior (ROA) position

3 Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Lie describes how the fetus is oriented to the mother's spine. Presentation refers to the fetal part that enters the pelvis first. Position refers to how a reference point on the fetal presenting part is oriented within the mother's pelvis.

For the previous 4 hours, a client in labor has been experiencing hypertonic labor as documented by the primary health care provider. The nurse recognizes which findings to be characteristic of this type of labor? Select all that apply. 1.Contractions typically occur in the latent phase of labor. 2.Contractions occurring every 8 minutes, lasting 40 seconds. 3.Contractions occurring every 2 minutes, lasting 70 seconds. 4.Hypertonic uterine dysfunction is most likely to occur in the multigravida. 5.Contraction force is felt in the midsection of the uterus rather than the fundus

1 3 5 Rationale: One of the most common types of dysfunctional labor is hypertonic labor, which tends to occur during the latent phase of stage 1 labor. A normal pattern during the latent phase of labor is contractions every 5 to 10 minutes, lasting 30 to 45 seconds, and mild in intensity. Hypertonic labor dysfunction is more common in primigravidas than multigravidas. Hypertonic contractions are uncoordinated and typically are more forceful in the midsection of the uterus.

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply. 1."Leopold's maneuvers are used to determine fetal position." 2."Leopold's maneuvers are used to determine actual fetal heart rate." 3."Leopold's maneuvers are used to determine duration of contractions." 4."Leopold's maneuvers are used to determine frequency of contractions." 5."Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6."Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."

1 5 6 Rationale: Leopold's maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal lie, attitude, position and presentation. Leopold's maneuvers also assist in determining the degree of fetal descent into the pelvis and in locating the point of maximal FHR intensity. Fetal heart rate is not determined by the performance of Leopold's maneuvers. Contraction duration or frequency is not established by performing Leopold's maneuvers.

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client? 1.The client lacks self-esteem from being ill. 2.The client feels hopeless about the situation. 3.The client is grieving because of her condition. 4.The client lacks knowledge about the disease process.

2. The client feels hopeless about the situation. Rationale: By seeing no way out of the situation except for death, the client is expressing hopelessness. A person who lacks hope feels that life is too much to handle. The data given do not support a lack of self-esteem. Grieving may be a possible problem at a later time; however, at this time, hopelessness should take precedence. Option 4 is a possible problem later, but the question does not contain enough data to support it at this point.

At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 11:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action? 1.Palpate the bladder for fullness. 2.Turn the client on her right side. 3.Prepare the client for a cesarean delivery. 4.Prepare the client for the induction of labor.

3 An indication for a cesarean delivery is the failure of labor to progress and fetal distress. In this situation, the nurse will prepare the client for this procedure. Clients are not turned on their right side for therapeutic reasons. Placing the client on the left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. While keeping the bladder empty facilitates the fetus's descent, it should have only a moderate effect on the client's current situation. Preparing for induction would not be indicated in this case because the client has been in labor for 9 hours and the FHR is beginning to decrease.

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure? 1."I'm getting tired of lying flat on my back." 2."I shut the machine off when I talk on the telephone." 3."What an efficient way to record my baby's heart rate." 4."How many volts of electricity are going through my body?"

3 Rationale: EFM is a method of recording the fetal heart rate. The woman is asked to assume a semi-sitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface; in this case, the fetal heart and valves. EFM does not need to be shut off when talking on the telephone.

The nurse is evaluating the effectiveness of meperidine hydrochloride for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief? 1.Contractions are longer, stronger, and closer together. 2.Pain level is "5" with increased amounts of bloody show. 3.Pain level is "4" while a progressive labor pattern continues. 4.Pain level is "0" and the client experiences a period of rest from labor contractions.

3 Rationale: Effective pain management during labor does not interrupt the labor process but does provide relaxation and moderate pain relief to the mother. The increased bloody show and intensity of the contractions are not measures of effective pain management.

A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate? 1.Prepare to induce labor. 2.Turn the client to the left side. 3.Prepare the client for a cesarean delivery. 4.Continue to monitor the fetal heart rate pattern.

3, Prepare the client for a cesarean delivery . Rationale: Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need to perform a cesarean delivery. Inducing labor is not indicated, in this case, because the client has been in labor for 12 hours without progress and with the presence of fetal distress. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava and would be implemented with any client in labor. Monitoring the fetal heart rate pattern is also appropriate for any client in labor, but it is not the most appropriate nursing action in this situation.

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares 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 infusion 4.Documenting the findings and continuing to monitor the fetal patterns

1 Late decelerations are due to uteroplacental insufficiency as the 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 decreased or discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions caused by the oxytocin. Documenting findings and continuing to monitor delay necessary treatment.

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

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 should not be encouraged to ambulate every 30 minutes but should be encouraged to rest.

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

2 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 1 and 4 are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleansing and changing clothing and may provide peripads to the client, but determining the fetal heart rate is the initial action.

The client is in the second stage of labor. As the baby begins to crown, the primary health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take? 1.Assess the client's blood pressure and fetal heart rate more frequently now. 2.Monitor more closely for fetal heart rate decelerations and loss of variability. 3.Assess the client's pulse and respirations every 2 minutes for the next 20 minutes. 4.Continue to assess vital signs and fetal heart rate the same as before the nerve block.

4 Pudendal nerve block may be used when an episiotomy is to be performed, if forceps or a vacuum extractor is to be used to facilitate birth, or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. Pudendal block does not change maternal hemodynamic or respiratory functions, vital signs, or the fetal heart rate because it is considered a local anesthetic. Therefore, the nurse should continue to assess vital signs and fetal heart rate the same as before the nerve block.

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed? 1.Locate fetal heart tones. 2.Warm the sonogram gel. 3.Have the client empty her bladder. 4.Have the client drink 8 ounces of water.

Have the client empty her bladder. Rationale: An empty bladder contributes to a woman's comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram (ultrasound). Often, Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones

The nurse is caring for a client in labor. The nurse reviews the primary health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. Which client statement indicates that the client understands the purpose of receiving this medication? 1."I should experience at least some pain relief shortly after receiving this medication." 2."My labor contraction pattern will become much stronger after I take this medication." 3."My labor contraction pattern will decrease some allowing for more rest time between contractions." 4."Taking this medication will allow my baby's lungs to mature In order to prevent respiratory problems following birth."

1 The woman in labor may be given parenteral analgesia during the first stage of labor, up to 2 to 3 hours before the anticipated delivery. Butorphanol tartrate is a medication that may be prescribed for pain relief. Altering the contraction pattern and assisting with fetal lung development are not actions of this medication

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor which criteria? 1.Effacement and dilation of the cervix 2.Frequency, duration, and intensity of contractions 3.The presence of both clear and red vaginal discharge 4.All vital signs, especially heart rate and blood pressure

All vital signs, especially heart rate and blood pressure In abruptio placentae, the placenta has become detached. It could be marginal where bleeding is noted or concealed where there is no evidence of bleeding. The client will manifest signs/symptoms of shock if bleeding occurs, and this complication will be noted by a change in vital signs. Although options 1, 2, and 3 identify items that will be monitored in the client in labor, these are not specifically associated with the subject of the question.

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care? 1.Administer antibiotics. 2.Maintain complete bed rest. 3.Notify the neonatal resuscitation team. 4.Maintain continuous electronic fetal monitoring.

4 Rationale: Maternal and fetal well-being is monitored before and during oxytocin administration; this includes monitoring fetal heart rate, uterine contractions and tone, and maternal blood pressure. No data in the question indicate the presence of maternal or fetal complications that would require antibiotics, complete bed rest, or notifying the neonatal resuscitation team.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1.Baseline fetal heart rate 2.Intensity of contractions 3.Maternal blood pressure 4.Frequency of contractions

Baseline fetal heart rate Rationale:The nurse should first determine the baseline fetal heart rate. Although options 2, 3, and 4 are components of the data collection process, the fetal heart rate is the priority.

the nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC? 1.Prolonged clotting times 2.Decreased platelet count 3.Swelling of the calf of one leg 4.Petechiae, oozing from injection sites, and hematuria

Swelling of the calf of one leg DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. Petechiae, oozing from injection sites and hematuria are associated with the presence of DIC. Swelling and pain in the calf of one leg more likely are associated with thrombophlebitis.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which? 1.Encourage immediate breastfeeding. 2.Complete routine newborn care measures quickly. 3.Determine the parents' desires for contact with the newborn. 4.Suggest the mother hold the newborn after the placenta is delivered.

3 Rationale: Although immediate contact may be important for attachment or breastfeeding, the parents' wishes concerning contact with their newborn must be supported and determined first. The remaining options would follow the initial intervention.

The nurse should prepare to give a prescribed oxytocic medication after delivery of which? 1.Placenta 2.Infant's body 3.Infant's head 4.Infant's shoulders

1 Oxytocics are administered because they stimulate the uterus to contract, thereby helping prevent hemorrhage after the placenta is expelled. If an oxytocic medication is prescribed, the nurse administers the medication after placental delivery.

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted? 1.Presence of accelerations 2.Evidence of fetal bradycardia 3.Presence of late decelerations 4.Decreased fetal heart rate variability

1 Rationale Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system. Bradycardia, late decelerations, and decreased variability are representative of decreased oxygenation of the fetus.

The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted? 1.Fetal tachycardia 2.Increased urinary output 3.Contractions occurring every 3 minutes 4.Soft uterine tone palpated between contractions

1 Rationale: Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia because of excessive uterine activity. The nurse should also ensure that the uterus maintains an adequate resting tone between contractions. Options 2, 3, and 4 are not indications of a problem.

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem? 1.Anxiety and fear 2.Feeling powerless 3.Lack of parenting skills 4.Lack of sensory perceptio

1. Anxiety and fear Rationale: The client is expressing anxiety and fear related to the situation. Powerlessness would be identified if the client verbalized a lack of control over the situation. Lacking parenting skills is unrelated to the situation. Lacking sensory perception may be displayed by confusion.

A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure? 1.A stress test 2.A cesarean birth 3.Internal uterine contraction monitoring 4.Frequent repositioning from the right to the left side

2 Early diagnosis of placental abruption is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood analysis, and either an immediate cesarean birth or vaginal delivery. Options 1, 3, and 4 are not helpful in managing this problem.

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal? 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 Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help 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 assisting in the care of a woman in labor should focus primarily on which client at the time of delivery? 1.Mother 2.Newborn 3.Support person 4.Primary health care provider

2 The nurse's primary responsibility at the time of delivery is focused on the infant. The primary health care provider is primarily responsible for the care of the mother. The support persons are responsible for themselves.

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response? 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver

2. Fear of losing control Rationale: Pains, helplessness, and fear of losing control are possible client responses in the transition stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, and low-pitched grunting sounds usually indicate a woman is working effectively with contractions. The Valsalva maneuver is performed by attempting to forcibly exhale while keeping the mouth and nose closed. This maneuver is used to evaluate the condition of the heart and is sometimes done as a treatment to correct abnormal heart rhythms or relieve chest pain.

The nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which condition becomes apparent? 1.Descent of less than 1 to 2 cm/hr 2.Latent phase of less than 6 hours 3.Decreased periods of uterine relaxation between contractions 4.Dilation of the cervix of greater than 1 and less than 5 cm/hr during the active phase

3. Decreased periods of uterine relaxation between contractions Rationale: A sign of a possible need for emergency intervention is inadequate uterine relaxation between contractions. Inadequate relaxation interferes with the transfer of oxygen and nutrients to the fetus through the mother's placenta. All other options are within normal limits for a nulliparous woman. By definition a precipitate labor lasts less than 3 hours.

The nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing which condition? 1.Abruptio placentae 2.Incompetent cervix 3.Marginal placenta previa 4.Complete placenta previa

4 Complete placenta previa completely covers the internal cervical os, whereas partial or marginal does not. The remaining options are not related to the condition defined in the item.

A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort? 1.Turn the client to the lateral position. 2.Assist the client to ambulate in the room. 3.Allow the client to sit on the side of the bed. 4.Place a pillow under one hip when lying in the supine position.

Assist the client to ambulate in the room. Ambulation should be avoided because the client is in active labor and received an analgesic 1 hour ago. Each of the other options identifies measures that are both safe and effective to reduce back discomfort for the client.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1.The maneuvers measure the height of the maternal fundus. 2.The maneuvers determine the "lie" and "attitude" of the fetus. 3.The maneuvers are a systematic method for palpating the fetus through the maternal back. 4.The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall. Rationale: Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 3 are incorrect descriptions.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse should suspect the client is how far dilated? 1.1 to 2 cm 2.3 to 4 cm 3.5 to 7 cm 4.8 to 10 cm

4 Rationale: During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply. 1.One vein 2.Two veins 3.One artery 4.Two arteries 5.One capillary 6.Two capillaries

one vein two arteries The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There are no capillaries.

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside? 1.Code cart 2.Suction machine 3.Nasogastric tube 4.Intravenous (IV) supplies

4 Rationale: The client who is a gravida VI is at risk for possible uterine atony. An IV access is needed so that blood and medication can be administered if necessary. Options 1, 2, and 3 are unnecessary items.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding? 1.Soft abdomen on palpation 2.Uterine tenderness on palpation 3.No complaints of abdominal pain 4.Lack of uterine irritability or tetanic contractions

2. Uterine tenderness on palpation Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which? 1.1 inch below the coccyx 2.1 inch below the iliac crest 3.1 cm above the ischial spines 4.1 fingerbreadth below the symphysis pubis

3 Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Options 1, 2, and 4 are incorrect.

The nurse is assigned to assist in caring for a client in labor. The nurse determines that which sign/symptom would least likely indicate dystocia? 1.Signs of fetal distress 2.Failure of a fetus to descend 3.Progressive changes in the cervix 4.High level of maternal fear or anxiety

3. Rationale: Progressive changes in the cervix are a reassuring pattern in labor. Abnormal labor patterns are assessed according to the nature of the cervical dilation and fetal descent. Options 1, 2, and 4 could indicate signs of dystocia.

If a precipitate delivery is imminent, which would be the appropriate nursing action? 1.Immediately contact the primary health care provider, and call for assistance. 2.Put on sterile gloves, and gently guide the baby's head and shoulders out. 3.Place the client in the Trendelenburg's position, and apply oxygen to the mother. 4.Medicate the mother, and delay the delivery until the primary health care provider arrives.

Put on sterile gloves, and gently guide the baby's head and shoulders out. The baby is the priority. In an emergency situation, the nurse assists the client in the delivery by donning sterile gloves and gently guiding the head and the shoulder of the baby. There is rarely time to notify the primary health care provider. Options 3 and 4 are inappropriate and could cause distress to the fetus.

The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which? 1.Leg pain 2.Signs of shock 3.Abdominal pain 4.Red vaginal discharge

Signs of shock The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock caused by bleeding in the abdomen. Leg pain, abdominal pain, and red vaginal discharge are not signs/symptoms of a ruptured uterus.

The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action? 1.Administer oxygen. 2.Monitor the fetal heart rate. 3.Notify the registered nurse immediately. 4.Place the client in the Trendelenburg's position.

2 When the membranes rupture, the fetus can drop down in the birth canal. This increases the chances of compressing the umbilical cord and compromising the oxygen flow to the fetus. The initial nursing action is to monitor the fetal heart rate. The Trendelenburg's position is used if the cord is compressed. The registered nurse needs to be notified, and oxygen may be administered to the client, but the initial action is stated in option 2.

A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority? 1.Continue to time the contractions. 2.Determine the need for education. 3.Give acetaminophen (Tylenol) for the temperature. 4.Report the time of last food intake to the primary health care provider.

4 Rationale: The nurse should report the time of last food intake to the primary health care provider because general anesthesia is sometimes used for an emergency birth. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Providing acetaminophen is incorrect because it requires a primary health care provider's prescription. The remaining options are correct nursing actions but are lesser priorities.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? 1.Estimate the fetal size. 2.Check pelvic adequacy. 3.Administer an analgesic. 4.Determine the maternal and fetal vital signs.

4 Rationale: To evaluate a woman's physical well-being, her temperature, pulse, respirations, and blood pressure (as well as the fetal heartbeat) are checked. Administering an analgesic is incorrect because it would be too premature for an analgesic; medication given too early tends to slow or stop labor contractions. Estimating fetal size and pelvic adequacy should have been previously performed by the health care provider during prenatal visits.

the nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement? 1."I'm having bloody show." 2."The contractions are intense." 3."My cervix is completely dilated." 4."My membranes are now ruptured."

3. "My cervix is completely dilated." Rationale: The second stage of labor begins when the cervix is completely dilated and ends with the birth of the infant. Bloody show, intense contractions and rupture of membranes can occur any time in labor.

A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action? 1.Check the fetal heart rate. 2.Monitor the contraction pattern. 3.Prepare the client for immediate delivery. 4.Note the amount, color, and odor of the amniotic fluid.

1 Rationale: When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 2 and 4 may also be a component of care but are not the immediate actions. There are no data to indicate that option 3 is necessary at this time.

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern? 1.105 beats per minute, minimal variability 2.150 beats per minute, moderate variability 3.170 beats per minute, absent variability 4.180 beats per minute, mild variability

2 The normal baseline fetal heart rate has a lower limit of 110 to 120 beats per minute and an upper limit of 150 to 160 beats per minute. Variability desired is moderate indicating a periodic change of 6 to 25 beats per minute. Options 1, 3, and 4 are incorrect based on FHR range.

The nurse is monitoring the status of a client in active labor. The nurse interprets that which findings are consistent with dystocia? Select all that apply. 1.Signs of fetal distress 2.High level of maternal anxiety 3.Failure of the fetus to descend 4.Leaking of a clear liquid from the vagina 5.Progressive but slow changes in the cervix

1 2 3 Rationale: Fetal distress, failure to descend, and extreme maternal anxiety are consistent with the findings that occur with dystocia. Progressive changes in the cervix are a reassuring pattern in labor while leaking amniotic fluid is a normal occurrence.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should 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

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus Rationale: Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abruptio placentae, the abdomen will feel hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1.A change in the uterine contour 2.Sudden and sharp abdominal pain 3.A shortening of the umbilical cord 4.A decrease in blood loss from the introitus

A change in the uterine contour Rationale: Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness, but not sudden and sharp abdominal pain.

The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose? 1.Assist the baby in engaging into the birth canal. 2.Achieve an accurate measurement of urinary output. 3.Reduce the risk of injuring the bladder during the surgery. 4.Help prevent the possibility of developing a bladder infection.

Reduce the risk of injuring the bladder during the surgery. A urinary catheter is inserted preoperatively to keep the bladder empty to reduce the risk of injury to the bladder when the surgical incision is made. The catheter would not assist the downward movement of the fetus.

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse? 1."Tell me what you mean when you say that your baby has moved." 2."The primary health care provider is all set to go and cannot change plans now." 3."That would be impossible because babies don't move around this late." 4."You need to listen to your primary health care provider; he knows what he is doing."

1 Rationale: Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 1 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 2, 3, and 4 do not and are blocks to communication.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1.Support the mother in her reaction to the newborn. 2.Encourage the mother to breastfeed soon after birth. 3.Tell the mother that it is important to hold the newborn. 4.Document a complete account of the mother's reaction in the birth record.

1 Rationale: Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn. Encouraging the mother to breastfeed, telling the mother the importance of holding her newborn and documenting the maternal reaction to the birth do not acknowledge the mother's feelings.

The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply. 1.Ease of administration 2.Absence of fetal hypoxia 3.Immediate onset of anesthesia 4.Blockade of sympathetic fibers 5.Increased voluntary expulsive efforts 6.Decreased incidence of bladder atony

1 2 3 Rationale: Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include ease of administration, absence of fetal hypoxia, and onset of anesthesia in 1 to 3 minutes. A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which findings indicate a need to contact the registered nurse (RN)? Select all that apply. 1.Hemoglobin of 11 g/dL 2.Blood pressure reading of 144/94 3.Fetal heart rate of 180 beats per minute 4.Maternal pulse rate of 85 beats per minute 5.White blood cell count of 12,000 mm3

2 3 A blood pressure reading of 144/94 is elevated for pregnancy. The client may need to be evaluated for preeclampsia or gestational hypertension. A normal fetal heart rate is 110 to 160 beats per minute. A count of 180 beats per minute could indicate fetal distress and needs to be reported. 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 total blood volume increases 30% to 50% by the end of the second trimester. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 18,000 mm3. During the immediate postpartum period the count may range from 25,000 to 30,000 cells/mm3 as a result of increased leukocytosis during delivery.

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problems should the nurse expect to note on the plan of care? 1.Anxiety related to a slow progress of labor 2.Anxiety related to previous parenting issues 3.Anxiety related to the inability to achieve relaxation 4.Anxiety related to physical and emotional maternal exhaustion

Anxiety related to a slow progress of labor An experience can be influenced by past experiences, culture, support from family or significant other, or by preparation. Dystocia can cause a slow progress of the labor. Maternal anxiety is compounded by the crisis of the slow labor. Options 2, 3, and 4 are unrelated to dystocia.

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client? 1.Up in chair 2.Ambulation 3.Complete bed rest 4.Bathroom privileges

Complete bed rest Rationale: Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action? 1.Notify the registered nurse. 2.Administer oxygen via face mask. 3.Place the mother in Trendelenburg's position. 4.Document the findings and continue to monitor the fetal patterns.

Document the findings and continue to monitor the fetal patterns. Rationale: Early deceleration of the FHR is a gradual decrease in and return to baseline FHR 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. The remaining options are unnecessary

The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note? 1.Latent phase of 2 hours 2.Descent of 1 cm per hour 3.Decreased periods of uterine relaxation between contractions 4.Dilation of the cervix of 2 to 4 cm per hour during the active phase

3. Rationale: Inadequate relaxation between contractions could interfere with the transfer of oxygen and nutrients to the fetus through the placenta. All other options are within normal limits for a nulliparous woman and do not require reporting.

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply. 1.Fundus nonpalpable 2.Constant fever of 101° F 3.Persistence of lochia alba 4.Persistent pelvic heaviness 5.Foul-smelling vaginal discharge

2 4 5 Subinvolution is a condition in which the uterus does not return to its normal size after childbirth. Manifestations include fever, pelvic pain or heaviness, red lochia (or return of bleeding after it has changed), or foul-smelling vaginal discharge. The uterine fundus is no longer palpable by 12 days postpartum; this is a normal finding and not indicative of subinvolution. Lochia alba is normal vaginal drainage at this time following delivery.

The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. 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

Monitoring fetal status The priority in the plan of care includes 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, the fetal status is the priority.

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority? 1.Has a urinary catheter been inserted? 2.Was the informed consent form signed? 3.When was the last time the client ate or drank? 4.Is there a current complete blood cell count result in the client's medical record?

When was the last time the client ate or drank? The status of oral intake is the most important data to collect. This information will provide the basis for the type of anesthesia used to prevent aspiration during surgery and postoperatively. Options 1, 2, and 4 are all routine preoperative procedures.

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms would indicate that the client's bleeding is caused by placenta previa? Select all that apply. 1.Rigid, boardlike abdomen 2.Bright red vaginal bleeding 3.Lack of uterine contractions 4.Pain rating of 6 on a scale of 1 to10 5.Fetal heart rate below 100 beats per minute

2 3 Signs/symptoms of placenta previa include bright red bleeding that is usually painless. The client doesn't experience contractions. These signs/symptoms are caused by the placenta's placement over or partially covering the cervix. Signs/symptoms of abruptio placentae include fetal distress; a rigid, boardlike abdomen; painful contractions; and dark vaginal bleeding. These signs/symptoms are caused by the placenta's separation from the uterus.

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply. 1.Encourage frequent urination. 2.Maintain absolutely nothing by mouth (NPO). 3.Continue maternal and fetal assessments. 4.Review breathing and relaxation techniques. 5.Provide a bed bath because the client cannot shower.

1 3 4 Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor. Maternal and fetal assessments are critical to determine the progress of labor and the safety of the mother and fetus. Breathing and relaxation techniques are reviewed during the latent phase and encouraged during the active phase. The client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid intake. The client may take showers.

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication? 1.High platelet count 2.Oozing from injection sites 3.A reddened rash over the trunk 4.Pain and swelling of the calf of one leg

2. Oozing from injection sites Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, which then leads to widespread bleeding. The client in DIC shows oozing from injection sites, petechiae, hematuria, and possibly other signs of bleeding. Platelets are decreased because they are consumed by the process; coagulation studies are prolonged because of a decreased ability to form clots. A red rash is not associated with this condition. Pain and swelling of the calf is incorrect because it describes deep vein thrombosis. DIC is a widespread coagulopathy throughout the microvasculature, not isolated in one blood vessel.

During the intrapartum period, the nurse is caring for a laboring client diagnosed with sickle cell disease. The nurse recognizes that which conditions are most likely to lead to a sickling crisis? Select all that apply. 1.Exertion 2.Infection 3.Hypoxemia 4.Dehydration 5.Analgesic administration

1 2 3 4 Rationale: Maintaining adequate IV fluid intake and administering oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor when the mother has sickle cell disease. A variety of conditions, including exertion, infection, hypoxemia and dehydration can stimulate the sickling process during the intrapartum period. Administering pain medication will not cause a sickle cell crisis.

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitudes? Select all that apply. 1.Alertness 2.Irritability 3.Excitement 4.Seriousness 5.Helplessness

1 3 Rationale: In early labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth and she is often alert and talkative related to what she is experiencing. Options 2, 4, and 5 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding is noted if complete rupture occurs? 1.Maternal bradycardia 2.Decreasing blood pressure 3.Excessive vaginal bleeding 4.Increased uterine contractions

2 Rationale: Complete uterine rupture results in massive blood loss; however, external bleeding may not be impressive because most of the blood is lost into the peritoneal cavity. Signs of shock as evidenced by a falling blood pressure; tachycardia; tachypnea; pallor; cool, clammy skin; anxiety; and pain develop quickly. Uterine rupture results in contractions ceasing.

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure? 1.Pelvic exam 2.Amniocentesis 3.Contraction stress test 4.Chorionic villus sampling

3 Rationale: A client with painless vaginal bleeding is at risk for going into labor, and a contraction stress test is indicated. The concern is that if fetal oxygenation is only marginally adequate when the uterus is at rest, it may be decreased further during uterine contractions. Amniocentesis and chorionic villi sampling are not appropriate at this time. A pelvic examination is contraindicated when there is vaginal bleeding.

During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which rationale should the nurse provide to the client for these interventions? 1."Adequate IV fluids and oxygen will stimulate and accelerate the labor process." 2."Administering IV fluids and oxygen will reduce the need for analgesic administration." 3."Providing adequate IV fluids and oxygen during the labor process will minimize the necessity of a cesarean delivery." 4."Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling."

4 A variety of conditions, including dehydration, hypoxemia, infection, and exertion can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for both the mother and fetus during labor. Options 1, 2, and 3 are incorrect

The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which issue? 1.Presence of edema 2.Signs of hyperglycemia 3.Presence of vaginal bleeding 4.Characteristics of contractions

4 Dystocia is a slowed labor process. A prolonged labor is a potential for fetal distress. The nurse would specifically monitor the characteristics of the contractions. Presence of edema, hyperglycemia, or vaginal bleeding is unrelated to this condition.

A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the oxytocin induction? 1.L/S ratio 2:1 2.Gestational diabetes 3.Hemoglobin level of 11.6 g/dL 4.Previous classical vertical uterine incision

4 Rationale: A previous classical vertical uterine incision is associated with a higher incidence of uterine rupture in subsequent pregnancies and may prohibit the use of an oxytocin induction. An L/S ratio of 2:1 indicates fetal lung maturity and is not a contraindication to an oxytocin induction. Gestational diabetes in a term pregnancy could warrant an induction of labor. A hemoglobin of 11.6 g/dL, is considered normal for a pregnant woman and would not interfere with scheduling an induction.

The nurse is assigned to care for a client experiencing dystocia. Which is the highest priority in planning care? 1.Comfort measures, change of position, and touch 2.Explanations to family members about what is happening in this situation 3.Reinforcement of breathing techniques learned in childbirth preparatory classes 4.Monitoring for changes in the physical and emotional condition of the mother and fetus

4 Rationale: All the options are correct and would be implemented during the care of the client. However, the highest priority is to monitor for changes in physiological integrity in both the mother and the fetus.

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock? 1.Cold and clammy skin 2.Decreased blood pressure 3.Restlessness and agitation 4.Diminished peripheral pulses

Restlessness and agitation Early signs of hypovolemic shock include restlessness, anxiety, and agitation. Later signs of hypovolemic shock include cold and clammy skin, a falling blood pressure, diminished peripheral pulses, pallor, and urine output less than 30 mL/hr. Options 1, 2, and 4 are all signs of late hypovolemic shock. Option 3 is the correct option.

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which signs as an indication of placental separation? Select all that apply. 1.Sudden abdominal pain 2.Change in uterine shape 3.Shortened umbilical cord 4.Lengthening of the umbilical cord 5.Decreased blood flow from the introitus 6.Sudden gush of dark blood from the introitus

2 4 6 Rationale: As the placenta separates, the uterus changes from a discoid to a globular shape. Other signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, and a firmly contracted uterus. The client may experience vaginal fullness but not sudden abdominal pain.

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip? 1.Age of client 2.Maternal vital signs 3.Last menstrual period 4.A temporary interruption in recording

2 Rationale: Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 1 and 3 are irrelevant.

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse would place the client at risk for uterine rupture? 1.Primigravidity 2.Shoulder dystocia 3.Hypotonic contractions 4.Weak bearing-down efforts

2. Shoulder dystocia Rationale: Shoulder dystocia at delivery causes increased pressure in the thin lower uterine segment and subsequently the risk for spontaneous rupture. Statistically, rupture is more common in multigravidas, especially when combined with the use of oxytocin. Hypotonic contractions and weak bearing-down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1.Determine the fetal heart rate. 2.Prepare for immediate delivery. 3.Monitor the contraction pattern. 4.Note the amount, color, and odor of the amniotic fluid.

1 Rationale: When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the contraction pattern and noting the amount, color, and odor of the amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery.

A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply 1.Nausea 2.Boardlike abdomen 3.Heavy vaginal mucus 4.Increase in fundal height 5.Early deceleration on the monitor

2 4 The signs of concealed bleeding include increase in fundal height, a hard boardlike abdomen, persistent abdominal pain, late decelerations in the fetal heart rate, or decreasing baseline variability. Nausea, heavy vaginal mucus and early decelerations are not signs of concealed bleeding.

A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. In addition to maintaining complete bed rest, which other actions should the nurse include in the plan of care? 1.Encourage fluids and reduce stimuli. 2.Monitor IV fluid intake and monitor the fetal heart rate. 3.Assist with the vaginal exam and restrict food and fluids. 4.Monitor IV fluid intake and monitor for uterine contractions

2 Initial nursing actions for care of a pregnant client with bleeding include maintaining complete bed rest (to reduce the chance for further bleeding), initiating and monitoring an IV (anticipating the need for fluid replacement), and monitoring the fetal heart rate (assessing the status of fetus). Food and fluid may or may not be restricted. Reducing stimuli is not a priority consideration. A vaginal exam is not appropriate because it may stimulate uterine contractions and increase bleeding.

Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta? 1.Wait 5 minutes for placental separation and then pull on the cord. 2.Pull gently on the cord following placental separation as the mother bears down. 3.Place traction on the cord and pull on the placenta as it enters the vaginal canal. 4.Encourage placental separation using forceps, and allow the placenta to deliver spontaneously.

2 Rationale: After the placenta separates, it usually can be delivered if the mother bears down. The cord may be gently pulled to assist in the delivery of the placenta. Excess traction on the cord may cause it to break, making the placenta harder to deliver. The remaining options are incorrect actions.

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage? 1.Effleurage is the application of pressure to the sacrum to relieve a backache. 2.Effleurage is light stroking of the abdomen to facilitate relaxation during labor. 3.Effleurage is a form of biofeedback to enhance bearing-down efforts during delivery. 4.Effleurage is a contracting of a specific muscle group while other parts of the body rest.

2 Rationale: 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. Options 1, 3, and 4 are incorrect descriptions.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? 1.Leopold's maneuvers 2.A manual pelvic examination 3.Hemoglobin and hematocrit evaluation 4.External electronic fetal heart rate monitoring

2 Rationale: Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia. Options 1, 3, and 4 are procedures that would not place the client at further risk.

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect? 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased blood pressure (BP) monitoring

2 Rationale: Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not create the need for increased monitoring of the BP.

The nurse is caring for a woman in the labor room. The health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication? 1.Resting interval of 50 seconds 2.Contraction duration of 75 seconds 3.Fetal heart tones of 154 beats/minute 4.Fetal variable decelerations lasting 60 seconds

Resting interval of 50 seconds Oxytocics are administered to augment labor because they stimulate the uterus to contract. Oxytocin is discontinued or its rate is reduced if signs of fetal compromise or excessive uterine contractions occur. Excessive uterine contractions are most often evidenced by contraction frequency greater than every 2 minutes, durations longer than 90 seconds, or resting intervals shorter than 60 seconds. Fetal heart tone rates are normally in a range of 110 to 160 beats/minute. Variable decelerations are abrupt decreases of 15 beats/minute below baseline, lasting 15 seconds to 2 minutes. These decreases begin and end abruptly; on the monitor they are V-, W-, or U-shaped.

The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which action at this time? 1.Change the woman to a side-lying position. 2.Administer oxygen at 8 to 10 L/min by face mask. 3.Notify the registered nurse of a possible prolapsed cord. 4.Notify the registered nurse of a possible maternal infection

Notify the registered nurse of a possible maternal infection. Signs of maternal infection include foul-smelling amniotic fluid, a maternal temperature in the presence of adequate hydration (adequate urine output), and fetal tachycardia. The nurse should inform the registered nurse of these data (who will then notify the primary health care provider) so that treatment can be initiated. Options 1, 2, and 3 are unrelated to the data in the question.

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

2 Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this should 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 positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's, prone, or Trendelenburg's position with the legs in stirrups is not practical for this type of abdominal surgery.

The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia? 1.Leopold's maneuver 2.McRoberts' maneuver 3.Placing the client in the lithotomy position 4.Positioning the client laterally on her left side

2 The McRoberts' maneuver is used to relieve shoulder dystocia. It is described as the woman flexing her thighs sharply against her abdomen to straighten the pelvic curve. This procedure will assist the fetus to move past the pelvic curve of the woman. Leopold's maneuver is used to locate the position and presentation of the fetus. Options 3 and 4 are positions, not techniques, and will not assist in relieving shoulder dystocia.

A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position? 1.Prone 2.Left lateral 3.High-Fowler's 4.Supine on the back

2 The left lateral position takes pressure off of the aorta and the inferior vena cava most effectively. This increases the blood supply to the uterus. The supine (on the back) position places pressure on the vena cava and could disrupt blood flow to the fetus. A high-Fowler's position could place excess pressure on the diaphragm. A prone position is incorrect and would affect contractions and the labor process and be very uncomfortable for the mother.

The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action? 1.Prepare for delivery. 2.Continue to monitor the client. 3.Report the FHR to the registered nurse. 4.Notify the registered nurse immediately about the progress of labor.

2 The normal fetal heart rate is 110 to 160 beats per minute. 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, persistently decreased variability, or an irregular FHR.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what? 1.General anesthesia 2.To be left totally alone 3.To push with her contractions 4.To regain her breathing pattern

4 Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated and the urge to push is present. The client may be terrified of being left alone during this phase of labor.

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor? 1.Reassure the client. 2.Maintain strict asepsis. 3.Prevent bearing-down. 4.Administer oxygen as prescribed.

4 Rationale: During the labor process, the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. An intervention to prevent sickle cell crisis during labor includes administering oxygen as needed. Options 1, 2, and 3 are accurate information but not for the situation described in the question.

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position? 1.Lithotomy 2.Knee-chest 3.Lateral Sims' 4.Semi-recumbent

3, Lateral Sims' Rationale: The lateral Sims' position places less stress on the perineum and increases the space needed for delivery. Because the upper leg is supported, the perineum can be better visualized as well. In addition, the lateral Sims' reduces the pressure of the gravid uterus on the mother's great vessels, so the circulation to the fetus is enhanced. The remaining options do not meet the current needs and so are not the best positions.

The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply. 1.Following directions readily 2.Talking about labor experience 3.Bearing down with contractions 4.Making expiratory vocalizations 5.Changing body positions frequently

3 4 5 Rationale: As the fetus's head moves through the vaginal canal (second stage, descent phase), the maternal behaviors noted include increased urge to push, grunting sounds or expiratory vocalization, frequent position changes, and altered respiratory patterns. Early in labor (stage 1) the client may be talkative and will readily follow directions.

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery? 1.Hemoglobin of 11.5 g/dL 2.Fetal heart rate of 154 beats per minute 3.Maternal pulse rate of 90 beats per minute 4.White blood cell count of 35,000 mm3

4 Rationale: White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 mm3 to 15,000 mm3 up to 18,000 mm3. A count of 35,000 mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of hemodilution caused by an increase in plasma volume during pregnancy. A normal fetal heart rate is 110 to 160 beats per minute.

The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time? 1.Report the fetal heart rate immediately. 2.Prepare for imminent delivery of the fetus. 3.Report the contractions because they reflect a potential complication. 4.Continue monitoring the client because the data reflect acceptable progress.

4 The normal fetal heart rate ranges from 110 to 160 beats per minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, or persistently decreased variability, and an irregular fetal heart rate. Based on the data in the question, the nurse should continue to monitor the client.

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time? 1. Change in position 2. Oral food and fluids 3. Intravenous analgesia 4. Rest between contractions

4 Rest between contractions Rationale: The birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy and facilitates voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which improves fetal tolerance of the stress of labor. No data in the question indicate that a change in position is necessary. Oral food and fluids is incorrect because food and fluids are likely withheld at this time, except for ice chips. Intravenous analgesia is incorrect because this action so close to delivery would likely cause central nervous system depression in the infant.

The nurse caring for a client who is receiving oxytocin for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which is the nurse's priority action? 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 knee-chest position.

1 Rationale: Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse should intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped. In addition, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/minute is administered. The registered nurse is immediately notified and will then contact the primary health care provider. The nurse should monitor the client's blood pressure and monitor intake and output. However, the nurse should first stop the infusion.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1.Squatting 2.Side-lying 3.Tailor sitting 4.Semi-Fowler's

2 Rationale: Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her side. Squatting, tailor sitting and semi-Fowler's position are incorrect because they would not prevent hypotension.

Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal? Select all that apply. 1.It is dark amber in color. 2.Amniotic fluid pH is basic. 3.It is light green with no odor. 4.It is thick and white with a musky odor. 5.It is pale, straw-colored with flecks of vernix. 6.A volume of 1000 mL is an acceptable amount of amniotic fluid.

2 5 6 Rationale: Amniotic fluid is basic with a pH over 7. Amniotic fluid is normally pale and straw-colored and may contain flecks of vernix caseosa. A normal amount of amniotic fluid at term ranges from 700 to 1000 mL. Amber fluid suggests the presence of bilirubin, whereas greenish fluid may indicate the presence of meconium and suggests fetal distress. It should have a watery, not thick, consistency and no odor.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety? 1.Emphasize the technical aspects of this type of delivery. 2.Decide how soon the client should see the baby after delivery. 3.Decrease the partner's anxiety by keeping him or her in the waiting area. 4.Encourage the client to discuss her concerns and desires regarding anesthesia options.

4 Rationale: Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse that do not involve client input. A woman undergoing cesarean delivery often feels disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help alleviate these feelings. Too much technical information may increase the client's anxiety. The presence of a support person is helpful.

The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply. 1.A soft and boggy uterus 2.The umbilical cord lengthens 3.Changes in the shape of the uterus 4.Maternal complaints of severe uterine cramping 5.A trickle or gush of blood escapes from the introitus

2 3 5 Rationale: Signs of placental separation include lengthening of the umbilical cord, a sudden trickle or gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness but not severe uterine cramping.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1.Prepare for an oxytocin infusion. 2.Keep the client in a side-lying position. 3.Prepare the client for epidural anesthesia. 4.Encourage the client to start pushing with the contractions.

Keep the client in a side-lying position. Rationale: Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury.

The nurse is providing emergency measures to a pregnant client 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 appropriately describes the mother's problem at this time? 1.Inability to cope 2.Deficient sensory perception 3.Fear about what is happening 4.Lack of control over the situation

3 Rationale: The mother is anxious and frightened and the most appropriate problem for the client at this time is fear about what is happening. No data in the question support the problems noted in the other options although they may be a consideration for this client at some point during the hospitalized experience.

A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply. 1.Low back pain 2.Uterus soft to palpation 3.Dark red vaginal bleeding 4.Frequent brief contractions 5.Bright red vaginal bleeding

2 5 The classic sign of placenta previa is the sudden onset of painless bright red vaginal bleeding. The uterus is soft with no abnormal contractions or irritability. Dark red bleeding accompanied by abdominal or low back pain is the typical characteristic of abruptio placentae. The woman's uterus is tender and unusually firm (boardlike) because blood leaks into its muscle fibers. Frequent, cramplike uterine contractions often occur (uterine irritability).

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1.Prone position 2.Semi-Fowler's position 3.Trendelenburg's position 4.Supine position with a wedge under the right hip

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

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should 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 Rationale: Rationale: 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 in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action? 1.Document the findings. 2.Transport the client to the delivery room. 3.Increase the rate of an oxytocin infusion. 4.Administer oxygen via face mask to the mother.

4. Administering oxygen via face mask Rationale: Late decelerations are caused by uteroplacental insufficiency that occurs as a result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when late decelerations are persistent. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the immediate action in this situation.