Unit 2: High-risk Intrapartum 2/5

A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time?

Notify the practicioner

The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first?

G1 P0000, 32 weeks, placental abruption, fetal heart (5 minutes ago) 120 bpm

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae?

G5 P1211, cocaine abuser

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications?

Abruptio placentae

A woman being induced with oxytocin (Pitocin) is contracting every 3 min × 30 seconds. Suddenly the woman becomes dypsneic and cyanotic and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority?

Administer oxygen

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply.

Breech presentation Station -3 Transverse lie

A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes × 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take?

Check dilation and effacement

A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take fi rst?

Check the fetal heart rate of a client who just ruptured membranes

Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor?

Client will exhibit normal breathing function at discharge

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these fi ndings as resulting from which of the following?

Cord compression

A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations, minimal variability, and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals?

Delivery of a healthy baby

A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time?

Fetal heart rate

A client is in active labor. Which of the following assessments would warrant immediate intervention?

Fetal scalp sampling pH of 7.19

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae?

Increasing fundal height measurements

The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus?

Late decelerations

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate?

Notify the physician of her request

Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 90 bpm with variable decelerations. A moderate amount of clear, amniotic fl uid is seen on the bed linens. The nurse concludes that which of the following has occurred?

Prolapsed cord

A laboring woman, who has developed an apparent amniotic fl uid embolism, is not breathing and has no pulse. In addition to calling for assistance, which of the following actions by the nurse, who is alone with the patient, is appropriate at this time?

Provide chest compressions at the depth of at least 2 inches

A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate?

Provide the woman with ongoing labor support

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform fi rst?

Put the client in the knee-chest position

The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as:

The results are equivocal, warranting further sampling

Given the fetal heart rate pattern shown below, which of the following interventions should the nurse perform first?

Turn the woman on her side