6700 Exam 3
The nurse is monitoring FHR of a client in term labor. The FHR varies between 120 and 130 beats/min over a 10-minute period. How would the nurse record the baseline?
125 beats/min After 10 minutes of tracing observed, the appx mean rate is rounded to the closest 5 beats/min interval which is 125 beats/min
Which laboring client would the nurse expect to be a likely candidate for amnioinfusion? A. A client with heavily meconium-stained amniotic fluid or a low amniotic fluid index B. A client with an increase in uterine activity (or a high amniotic fluid index) C. A client with HTN and diabetes during the 3rd trimester D. A client with an overdistended uterine cavity during the 2nd stage of labor
A. A client with heavily meconium-stained amniotic fluid or a low amniotic fluid index Amnioinfusion: infusion of room-temp isotonic fluid into the uterine cavity when the volume of amniotic fluid is low.
Which condition places the pregnant client at a higher risk for a cesarean delivery? A. A client with the fetus in a transverse lie B. A client with the fetus in a cephalic presentation C. A client with the fetal biparietal diameter of 9.25 cm at term D. A client in whom the presenting part is 4 cm below the spines
A. A client with the fetus in a transverse lie A transverse lie indicates that the long axis of the fetus is at a right angle, diagonal to the long axis of the mother. As a result, vaginal birth is not possible and client would need a c-section.
Which type of vaginal discharge is more common during the transition phase of first stage of labor? A. Bloody mucus B. Pale pink mucus C. Brownish discharge D. Pink-to-bloody mucus
A. Bloody mucus During transition phase, cervix is dilated 8-10 cm resulting in bloody mucus in vaginal discharge. Pale pink mucus seen in latent phase (cervix not dilated more than 3 cm). Brownish discharge may be observed during latent phase of 1st stage of labor. Pink to bloody mucus observed in active phase of cervical dilation.
The nurse caring for a laboring client is aware that maternal cardiac output can be increased by which factor? A. Change in position B. Oxytocin administration C. Regional anesthesia D. IV analgesic
A. Change in position Encourage client to change positions and avoid the supine position
During which period would the health care provider perform an episiotomy for a client who is expected to deliver a newborn who is large for gestational age? A. During crowning B. Before pushing C. During tearing of the perineum D. During delivery of the shoulders
A. During crowning Episiotomies not routinely performed unless necessary. Done during crowning to avoid maternal soft tissue damage.
Which parameter is closely monitored in a client during the latent phase of the first stage of labor? A. FHR B. Cervical dilation C. Maternal temperature D. External cephalic version
A. FHR Monitor FHR every 30-60 minutes
Which would the nurse be prepared to record before the health care provider artificially ruptures a laboring client's membranes? A. FHR B. Contraction pattern C. Maternal temperature D. Group B streptococcus status
A. FHR Risk of prolapsed umbilical cord when membranes rupture. Essential to closely monitor FHR pattern. Assess maternal temp and contraction pattern throughout labor. Group B strep status should be evaluated when client is admitted to the unit.
Which are characteristics of a uterine contraction? A. Frequency (how often contractions occur) B. Intensity (strength of the contraction at its peak) C. Resting tone (the tension in the uterine muscle between contractions) D. Appearance (shape and height) E. Attitude (the way the uterus presents itself)
A. Frequency (how often contractions occur) B. Intensity (strength of the contraction at its peak) C. Resting tone (the tension in the uterine muscle between contractions) Uterine contractions described in terms of frequency, intensity, resting tone, and duration.
Which of the following choices includes the correct order of the cardinal movements of labor? A. Internal rotation, extension, restitution B. External rotation, descent, extension C. Extension, flexion, internal rotation D. External rotation, expulsion, extension
A. Internal rotation, extension, restitution
The nurse is monitoring the FHR of a full-term client in labor. Which measure would the nurse take to obtain the most accurate baseline FHR? A. Record or monitor a 10-minute segment of tracing. B. Include periods of marked variability in the segment. C. Include episodic changes in the segment of tracing. D. Obtain at least 5 minutes of interpretable data in the segment.
A. Record or monitor a 10-minute segment of tracing. Baseline FHR is the avg rate during a 10-minute segment. Should not include periods of marked variability or episodic changes. Ensure there are at least 2 minutes of interpretable baseline data in a 10-min segment of tracing.
The nurse assesses fetal well-being during labor by monitoring which factor? A. Response of FHR to uterine contractions B. Maternal pain control to uterine contractions C. Accelerations in FHR D. FHR greater than 110 beats/min
A. Response of FHR to uterine contractions
Which are factors that accelerate dilation of the cervix? A. Strong uterine contractions B. Scarring of the cervix C. Pressure by amniotic fluid D. Prior infection of the cervix E. Force by fetal presenting part
A. Strong uterine contractions C. Pressure by amniotic fluid E. Force by fetal presenting part
What is an abnormal finding in a fetus during labor? A. The FHR is 190 beats/min at term B. The fetal head is in a synclitic position C. The fetal oxygen pressure decreases D. The fetal circulation is decreased
A. The FHR is 190 beats/min at term Normal FHR at term is 110-160 beats/min
When assessing uterine activity, the nurse is aware of which consideration? A. The examiner's should be placed on the fundus before, during, and after contractions B. The frequency and duration of contractions are measured in seconds for consistency C. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together D. The resting tone between contractions is described as either placid or turbulent
A. The examiner's should be placed on the fundus before, during, and after contractions
The client is in the 3rd trimester of pregnancy and reports pain in the pelvic joints. The nurse knows that the pain is caused by which factors? A. There is a relaxation of the pelvic joints. B. There is decreased mobility of the ligaments. C. The joint of the symphysis pubis is narrowing. D. The pelvis may not support vaginal birth.
A. There is a relaxation of the pelvic joints.
Which statement is accurate regarding episodic accelerations in FHR with fetal movement when caring for a laboring client? A. They are reassuring of fetal well-being B. They are caused by umbilical cord compression C. They warrant close observation of the fetus D. They result from uteroplacental insufficiency
A. They are reassuring of fetal well-being
Ms. Wildflower just got out of the tub. Her contractions have become stronger and more regular. She cannot speak during contractions. These findings are consistent with: A. True labor B. False labor C. Preterm labor D. Placenta previa
A. True labor
Which is the most appropriate time to determine the station of the presenting part in a pregnant client? A. When labor begins B. One week before labor C. During the 4th stage of labor D. At the end of the 3rd stage of labor
A. When labor begins Station: relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. Birth is imminent when presenting part is +4 cm to +5 cm below the spine.
Which is a part of the role of doula care for a laboring client? A. Administering analgesics B. Providing comfort measures C. Interpreting the fetal heart pattern D. Providing support to the client's partner E. Providing coaching during the second stage of labor
B, D, & E
The nurse instructor is teaching a group of students about the structure of the fetal head during labor and birth. Which statement indicates effective learning? A. "The fetal skull bones are firmly united during labor." B. "The fetal skull bones are united by membranous sutures." C. "The two important fontanels are the parietal and temporal." D. "The sutures and fontanels restrict brain growth after delivery."
B. "The fetal skull bones are united by membranous sutures." Fetal skull bones are flexible at birth and a slight overlapping of the bones may occur during labor. Two important fontanels are the anterior and posterior. The sutures and fontanels do not close at birth but instead allow flexibility to accommodate the brain, which continues to grow after birth.
During the vaginal examination of a laboring client, the nurse assesses that the fetus is in the right occiput anterior position at -1 station. Which position is the lowermost portion of the fetal presenting part? A. 2 cm above the ischial spine B. 1 cm above the ischial spine C. 2 cm below the ischial spine D. 1 cm below the ischial spine
B. 1 cm above the ischial spine When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being -1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines, the station is referred to as 0. When the presenting part is 1 cm below the spines, the station is said to be +1
The primary health care provider has asked the nurse to draw blood for an umbilical cord acid-base determination test. Which intervention would the nurse perform in this situation? A. Administer terbutaline before the test. B. Collect blood from both the umbilical artery and umbilical vein. C. First perform the fetal scalp stimulating technique. D. Only collect blood from the baby's umbilical artery.
B. Collect blood from both the umbilical artery and umbilical vein. Acid-base determination test done to assess immediate condition of neonate after birth if there is an abnormal or confusing FHR found during labor. Terbutaline given to decrease uterine contractions if they are too frequent. Fetal scalp stimulating done to assess fetal blood pH.
Which characteristic is associated with false labor contractions? A. Painless B. Decrease in intensity with ambulation C. Regular pattern of frequency established D. Progressive in terms of intensity and duration
B. Decrease in intensity with ambulation False labor contractions: decrease with activity, contractions felt in the back of the abdomen above the umbilicus. True labor contractions: painful, enhanced/stimulated with activity, regular pattern of frequency, progression of intensity and duration.
Which nursing action would be taken immediately following the vaginal birth of a healthy term newborn? A. Placing a hat on the infant before drying B. Drying the infant on the mother's chest and then placing a hat on the infant C. Drying the infant in the warmer and then initiating skin-to-skin contact D. Removing wet blankets from delivery and placing a hat on the infant
B. Drying the infant on the mother's chest and then placing a hat on the infant
Which FHR tracing characteristics are considered reassuring or normal (category I)? A. Bradycardia not accompanied by baseline variability B. Early decelerations, either present or absent C. Sinusoidal pattern, either present or absent D. Tachycardia not accompanied by baseline variability
B. Early decelerations, either present or absent Normal category I: early decelerations, absence of late decelerations, and presence of accelerations Category II: bradycardia, fetal tachycardia Category III: sinusoidal pattern
You have just administered 1mg of Stadol IV to Ms. Sweet who is 5cm/100/0 station. All of the following are required for comprehensive nursing care except: A. Evaluate the response to the analgesia B. Encourage ambulation C. Put two side rails up D. Document the analgesia dose, route, and time
B. Encourage ambulation
Ms. Pans is having contractions that are irregular and lessen in intensity and frequency with walking. These findings are consistent with: A. True labor B. False labor
B. False labor
Which location would the nurse utilize to assess and hear loud, clear fetal heart sounds? A. Fetal head B. Fetal back C. Fetal neck D. Fetal abdomen
B. Fetal back Nurse would locate fetal back to listen and count the heart sounds.
The nurse is assessing the FHR tracing for a client and determines a FHR baseline of 175 beats/min. The nurse knows this can be caused by which factor? A. Fetal ischemia B. Fetal tachycardia C. Fetal bradycardia D. Fetal hypotension
B. Fetal tachycardia Normal FHR is 110-160 beats/min
Ms. Bluebell is a G5P4004 who presents to OB triage at 40 weeks gestation to see if she is in labor because she contracted for several hours last night. Her contractions stopped 1 hour ago. Her cervix is 2/100/-3. Which of the following is an accurate assessment of Ms. Blueberry? A. First stage-transition phase B. First stage-latent labor C. False labor D. Second stage
B. First stage-latent labor
Which shape is the classic female pelvis shape and most conducive to a vaginal labor and delivery? A. Android B. Gynecoid C. Platypelloid D. Anthropoid
B. Gynecoid
Ms. Green is in active labor and just experienced a rupture of membranes and a bradycardia. On vaginal examination you feel the umbilical cord in the vagina. Which of the following is the priority? A. Leave the room and call for help B. Keep your fingers in the vagina to keep pressure off the cord C. Prepare for an emergency cesarean D. Place a fetal scalp electrode
B. Keep your fingers in the vagina to keep pressure off the cord
The nurse observes late decelerations in the FHR in the 2nd stage of labor. After assessing the client, the nurse elevates the lower extremities. Which assessment finding would be the reasoning for this nursing intervention? A. Placental abruption B. Maternal hypotension C. Maternal hemorrhage D. Uterine contractions
B. Maternal hypotension Elevate lower extremities to increase blood flow to uterus and control hypotension
Which client finding indicates a potential risk for complications during the labor process? A. Maternal temperature of 99.7 F B. Persistent dark red vaginal bleeding C. Intrauterine pressure of 50 mm Hg D. Contractions lasting for 70 seconds
B. Persistent dark red vaginal bleeding Indicative of old uterine bleed that was left untreated. May indicate fetal hypoxia. Intrauterine pressure greater than 80 mm Hg would indicate potential complication. Contractions lasting more than 90 seconds may increase risk during labor.
The nurse is providing care during labor for a client with twins and instructs the client to avoid lying flat on the back. Which condition would the nurse aim to prevent in the client during labor? A. Valsalva maneuver B. Supine hypotension C. Respiratory alkalosis D. Painful uterine contractions
B. Supine hypotension Can occur when ascending vena cava and descending aorta are compressed causing hypotension. Respiratory alkalosis could occur from hyperventilation.
Which statement is accurate regarding caring for a client in the 3rd stage of labor? A. The placenta eventually detaches itself from a flaccid uterus. B. The duration of the 3rd stage may be short and lasts from birth of the fetus until the placenta is delivered. C. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. D. The major risk for women during the 3rd stage of labor is the rapid HR.
B. The duration of the 3rd stage may be short and lasts from birth of the fetus until the placenta is delivered. Major risk during 3rd stage of labor is postpartum hemorrhage.
Which nursing instruction would ensure fetal safety during the second stage of labor? A. "Push continuously on command." B. "Hold your breath and push." C. "Push when you feel the urge." D. "Hold your breath, and push with maximum effort."
C. "Push when you feel the urge."
In which stage of labor would the nurse expect the placenta to be expelled? A. 1st B. 2nd C. 3rd D. 4th
C. 3rd 1st stage: lasts from time dilation begins to when cervix is fully dilated 2nd stage: lasts from time of full cervical dilation to the birth of the infant 3rd stage: placenta is expelled 4th stage: lasts for the first 2 hours after birth
Ms. Fern presents for an Induction of Labor (IOL) at 41 weeks. Her vaginal exam: 1/50/-1 vertex. The cervix is also soft and anterior. The nurse reports the Bishop's score to the provider as: A. 4 B. 6 C. 8 D. 10
C. 8
Which clinical findings are associated with the early phase of labor for a nulliparous client who is 2 cm dilated? A. Zero station B. Bloody mucus C. Client takes direction easily D. Scant amount of vaginal discharge E. Presence of mild to moderate contractions
C. Client takes direction easily D. Scant amount of vaginal discharge E. Presence of mild to moderate contractions Bloody mucus and zero station found when client is dilated 6-10cm
Ms. Geranium is in active labor and did not take childbirth classes. She is crying in pain and asking for help. Which of the following is an appropriate nursing intervention in this situation? A. Remind her to take classes before her next birth B. Tell her to do deep breathing and relaxation C. Demonstrate breathing techniques she can apply immediately D. A & B
C. Demonstrate breathing techniques she can apply immediately
The nurse instructs a laboring client to breathe through the mouth and keep it open while pushing during 2nd stage of labor. Which is the rationale for this intervention? A. Avoid nasal pressure in the client B. To decrease efforts required for pushing C. Facilitating increased oxygen to the fetus D. To avoid deceleration in FHR
C. Facilitating increased oxygen to the fetus
Ms. Chicory is in active labor and having an epidural placed. Which of the following is an epidural related risk that the nurse should be alert for? A. Decreased FHR variability B. HTN C. Hypotension D. Dysfunctional labor E. C & D
C. Hypotension
Ms. Pear is 16 year old G1P0 who is at 41 3/7 weeks gestation and was just admitted for induction of labor. Her cervix is 1/thick/-3. She has an order for Cervidil. How would you explain the purpose of this medication to Ms. Pear? A. It is an oxytocic medication that stimulates contractions of the uterus B. It opens the cervix mechanically as the Cervidil expands in the os C. It is a prostaglandin that acts by breaking down the connective tissues in the cervix D. It is a parenteral medication for labor induction that is administered via infusion pump
C. It is a prostaglandin that acts by breaking down the connective tissues in the cervix
When assessing the FHR of a client in labor, which would the nurse identify as normal variability of the FHR? A. Absent variability B. Minimal variability C. Moderate variability D. Marked variability
C. Moderate variability Moderate variability is high predictive of a normal fetal acid-base balance. Indicates that FHR regulation is not significantly affected by fetal sleep cycles, tachycardia, prematurity, congenital anomalies, preexisting neurologic injury, or CNS depressant meds. Absent or minimal variability is abnormal or indeterminate. Can result from hypoxemia or metabolic acidemia.
Ms. Mango returns to bed and the fetal head is visible. The CNM provider is at the bedside supporting Ms. Mango. Ms. Mango is making noise with spontaneous pushing. Which of the following nursing care strategies supports spontaneous pushing? A. Count to 10 while Ms. Mango pushes B. Encourage her to take a deep cleansing breath C. Remain present & use words of encouragement & support D. Place Ms. Mango's legs in stirrups for support and leverage
C. Remain present & use words of encouragement & support
Ms. Orchid is a healthy G1P0 at full term in early labor. Her birth plan that indicates that she desires to avoid an IV. The physician calls and orders IV fluid administration. Which of the following represents sound nursing care? A. Ignore the IV order and follow Ms. O's birth plan B. Administer the IV as ordered C. Remind the physician of Ms. O's birth plan and desires to avoid an IV D. Recommend an epidural
C. Remind the physician of Ms. O's birth plan and desires to avoid an IV
Which device can be used as a noninvasive way to assess FHR in a client whose membranes are not ruptured? A. Tocotransducer B. Spiral electrode C. Ultrasound transducer D. Intrauterine pressure catheter (IUPC)
C. Ultrasound transducer Ultrasound transducer: assess FHR through external mode; doesn't require membrane rupture or cervical dilation Tocotransducer: assess uterine activity in a pregnant client whose cervix is not sufficiently dilated, but it does not assess FHR Spiral electrode: internal mode of electronic fetal monitoring to assess FHR; requires membrane rupture and cervical dilation during intrapartum period IUPC: internal mode assessment of uterine activity; requires membrane rupture and cervical dilation during intrapartum period
When monitoring the client in labor, the nurse knows that the likely cause of variable FHR decelerations is which factor? A. Uterine tachysystole B. Maternal HTN C. Umbilical cord compression D. Epidural or spinal anesthesia
C. Umbilical cord compression
While assessing a pregnant client who is in labor, the nurses W-shaped waves on the FHR monitor. Which situation would the nurse infer from this observation? A. Placental abruption B. Dilated cervical layers C. Umbilical cord compression D. Elevated uterine contractions
C. Umbilical cord compression Indicative of variable decelerations in FHR. Seen when the cord is compressed at time of labor. Placental abruption, dilated cervical layers, and increased rate of uterine contractions can cause late decelerations in FHR.
Which client behavior is expected during the transition phase of the first stage of labor? A. Remains calm and silent B. Doubts her ability to control pain C. Vomits D. Attention is directed inward
C. Vomits 1st stage: strong uterine contractions, severe pain, hyperventilation (N/V). Latent phase of uterine contractions: may remain calm and silent, as urge to bear down isn't strong yet. Active phase: may become doubtful of ability to control pain
When caring for a client in labor, which instruction would the nurse provide in the 2nd stage of labor? A. "Point your toes to prevent pain" B. "Avoid fluids until the infant is delivered" C. "Lie still and avoid movement to prevent fatigue" D. "Avoid holding your breath or tightening the abdominal muscles"
D. "Avoid holding your breath or tightening the abdominal muscles" Avoid the Valsalva maneuver. Don't point toes, may cause leg cramps. Drink water if thirsty to prevent dehydration.
Which statement describes the nursing instructions for a client in the second stage of labor with an epidural? A. "Take a big deep breath in, and push down during your contraction." B. "When you feel rectal pressure, take a cleansing breath in and push down." C. "Only push if you feel like you need to, otherwise take slow deep breaths." D. "Take a deep breath in, and let your breath out slowly while pushing down."
D. "Take a deep breath in, and let your breath out slowly while pushing down." 2nd stage of labor consists of active pushing phase. Instruct client to use open-glottis pushing to promote fetal oxygenation. Do not bear down (Valsalva maneuver). Essential for client to push during contractions in the 2nd stage of labor.
The nurse is teaching a group of student nurses about fetal oxygenation. The nurse asks a student, "What happens when oxytocin levels are elevated in the client?" Which statement by the student nurse indicates effective learning related to the client's condition? A. "Hemoglobin levels will decrease" B. "Blood glucose levels will increase" C. "There is a lower blood supply to the placenta" D. "Uterine contractions will increase"
D. "Uterine contractions will increase" Oxytocin increases uterine contractions.
Ms. Mango is being monitored intermittently and is beginning to feel the urge to push. She wants to go to the bathroom to have a bowel movement. Which of the following assessments should the nurse make before Ms. Mango goes to the bathroom? A. Vaginal examination B. Fetal heart tones C. Blood pressure D. A & B
D. A & B
Ms. Grape is 40 year old G2P1001 who is in active labor. Her cervical exam is 4/80/0. She wants analgesia. You receive an order for Stadol 1 mg IV. Which of the following is consistent with the standard of practice for analgesia? A. Administer the medication and then accompany Ms. Grape for a walk in the hall B. Take the external monitor off for two hours for Ms. Grape to sleep C. Giver her only 0.5mg since this dose is too high to be safe D. Administer the medication during a contraction and then place two side rails up
D. Administer the medication during a contraction and then place two side rails up
Ms. Pineapple is a G2P1001 who has been in labor for 8 hours. The fetal heart tones are Category 1. She has had no cervical change since (5/100/0 3) hours ago. Her contractions are 3-5 min apart and palpate mild. Which of the following is important to communicate with the provider? A. The frequency of contractions B. The status of the fetal heart tones C. The vaginal examination D. Any abnormal vital signs D. All of the above
D. All of the above
While assessing a pregnant client using a fetoscope, the nurse also palpates the client's abdomen because of which factor? A. Detection of FHR deceleration B. Evaluation of the severity of pain caused by active labor C. Assessment of pain from pressure applied by the fetoscope D. Assessment of changes in FHR during and after contraction
D. Assessment of changes in FHR during and after contraction
The PHCP prescribes terbutaline for a pregnant client. After assessing the client's record, the nurse knows the rationale for this prescription should be which condition? A. Blood volume is elevated. B. Hemoglobin is decreased. C. BP is reduced. D. Contractions are increased.
D. Contractions are increased. Terbutaline slows down contractions.
While performing a vaginal examination for the client in active labor, the nurse notes early decelerations in the FHR during uterine contractions. Which nursing intervention is appropriate? A. Stop applying fundal pressure B. Discontinue oxytocin drip C. Change maternal position D. Document it as a normal finding
D. Document it as a normal finding Early decelerations are common during uterine contractions.
Which degree of severity is indicated for a client's perineal laceration involving the anterior rectal wall during childbirth? A. First degree B. Second degree C. Third degree D. Fourth degree
D. Fourth degree Defined in terms of depth of laceration. 1st degree: extend through skin and structures superficial to the muscle 2nd degree: extend through muscle 3rd degree: continue through anal sphincter muscle 4th degree: involve anterior rectal wall
The nurse is evaluating the fetal monitor tracing of a client who is in active labor and notes a sudden drop in FHR from its baseline of 125 down to 80. The nurse repositions the client, provides oxygen, increases IV fluid, and performs vaginal examination. The cervix hasn't changed. 5 minutes have passed, and the FHR remains in the 80s. Which additional measure would the nurse take? A. Call for help B. Insert a Foley catheter C. Start oxytocin D. Immediately notify the primary health care provider
D. Immediately notify the primary health care provider Stop any oxytocin if it's infusing. Client may need c-section.
Which device would the nurse use for monitoring the intensity of uterine contractions in a pregnant client? A. Tocotransducer B. Spiral electrode C. Ultrasound transducer D. Intrauterine pressure catheter (IUPC)
D. Intrauterine pressure catheter (IUPC) IUPC measures frequency, duration, and intensity of contractions in intrapartum period. Record pressure at catheter tip. Accurate readings require ruptured membranes and cervical dilation. Tocotransducer monitors frequency and duration of contractions for both antepartum and intrapartum care. Placed on client's abdomen. Spiral electrodes (invasive) and ultrasound transducers (noninvasive) are used to assess FHR.
Which supportive care measure is appropriate for a client complaining of back labor pain? A. Lie on her back for a while with her knees bent B. Do less walking C. Take deep, cleansing breaths D. Lean over a birth ball with her knees on the floor
D. Lean over a birth ball with her knees on the floor Do not lay supine. Hands-on-knees position helps with back pain.
During a prenatal evaluation, the nurse notes that the client has a flat pelvis. Which term would the nurse use in documenting the findings? A. Gynecoid B. Android C. Anthropoid D. Platypelloid
D. Platypelloid Platypelloid: flat and wide Gynecoid: classic type; slightly ovoid and transversely rounded Android: resembles male pelvis; heart shaped Anthropoid: resembles apes; oval and wider
While caring for a client receiving a nonstress test (NST), the nurse does not observe accelerations in the FHR after 30 minutes of FHR monitoring. Which intervention would the nurse perform to elicit FHR accelerations? A. Place client in lateral position B. Help the client elevate her legs C. Administer oxygen by face mask D. Provide vibroacoustic stimulation
D. Provide vibroacoustic stimulation
During the vaginal examination of a client in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation would the nurse recognize? A. Cephalic B. Frank breech C. Complete breech D. Shoulder
D. Shoulder Presenting part: part of fetus that lies closest to the internal os of the cervix. Cephalic: head presents Frank breech: sacrum presents Complete breech: sacrum and feet present
The nurse is caring for a client in the first stage of labor and notes that the client has scarring on her cervix as a result of a past STI. Which complication would the nurse predict in the client during labor? A. Ferguson reflex B. Slow fetal descent C. Supine hypotension D. Slow cervical dilation
D. Slow cervical dilation This is because the dilation occurs by drawing upward of the musculofibrous components of the cervix. Ferguson reflex: refers to maternal urge to bear down when the stretch receptors in the posterior vagina release endogenous oxytocin. Epidural analgesia may slow fetal descent. Supine hypotension occurs as a result of a drop in hydrostatic pressure.
Ms. Sunflower is a 25 year old G1P0 who is completely dilated and has no urge to push. Using the re-conceptualized second stage labor approach the nurse implements which of the following? A. Have her hold her breath with each contraction B. Count to 10 while she pushes with vigorous efforts C. Hold her legs back D. Wait for her to have an urge to push before supporting spontaneous pushing
D. Wait for her to have an urge to push before supporting spontaneous pushing
Ms. Rose who states that she "thinks" she is in labor enters the birth center. Which of the following assessments will help the nurse determine if Ms. Rose's is in labor? A. Leopold's maneuvers B. Uterine contractility C. Fetal HR assessment D. Vaginal examination E. B & D
E. B & D
During the process of birth Ms. Bloom's baby's head is born but the shoulders did not deliver. The physician is present. Which of the following is the nurse's priority? A. Prepare for a cesarean B. Get forceps C. Prepare to do suprapubic pressure D. Call for help E. C & D
E. C & D
Ms. Mum's last vaginal exam was 8/100/0. She is lying supine and states she is comfortable. Which of the following nursing interventions would reduce pain perception as well as the risk of vena cava compression? A. Reinforce her remaining supine to maximize her comfort B. Move her legs into stirrups to get her ready for pushing C. Encourage a position change to a non-supine position D. Offer to move Ms. Mum to one side E. C & D
E. C & D
