Ch. 14 Nursing Management During Labor & Birth NCLEX

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation

The nurse caring for a client in preterm labor observes non reassuring FHR patterns. Which of the following nursing interventions should the nurse perform?

Administration of O2 by mask

The nurse performing Leopold's maneuvers for a pregnant client explains to the client the purpose of the maneuvers. Which of the following is the purpose of the maneuvers? (Select all)

Determining the presentation of the fetus; determining the position of the fetus; determining the lie of the fetus

A pregnant client with a history of spinal injury is being prepared for cesarean birth. Which of the following methods of anesthesia is to be administered to the client?

General anesthesia

A client in labor is administered lorazepam to help her release enough so that she can participate effectively during her labor process rather than fighting against it. Which of the following is an adverse effect of the drug that the nurse should monitor for?

Increased sedation

A nurse is teaching a couple about patterned breathing during their childbirth education. Which of the following techniques should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips

A pregnant client has opted for hydrotherapy for pain management during labor. Which of the following should the nurse consider when assisting the client during the birthing process?

Initiate the technique only when the client is in active labor.

A nurse is required to obtain the FHR for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

Lower quadrant of the maternal abdomen

A pregnant client is admitted with vaginal bleeding. The nurse performs a nitrazine test to confirm that the membrane have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 & 6. What does this indicate?

Presence of vaginal fluid

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated FHR changes. What interventions should the nurse perform to manage the changes?

Provide supplemental O2

A nurse is caring for a client who has been administered an epidural block. Which of the following symptoms must the nurse monitor the client for?

Respiratory depression

A pregnant client requires administration of an epidural block for management of pain during labor. Which of the following conditions should the nurse check for in the client before administering the epidural block? (Select all)

Spinal abnormality; hypovolemia; coagulation defects

A nurse caring for a pregnant client in labor observes that the FHR is below 110. Which of ht following interventions should the nurse perform? (Select all)

Turn the client on her left side; administer O2 by mask; assess client for underlying causes

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. What complications associated with general anesthesia should the nurse monitor for?

Uterine relaxation

A nurse assisting a pregnant client during pregnancy is to monitor uterine contractions. Which of the following factors should the nurse assess to monitor uterine contractions? (Select all)

Uterine resting tone; frequency of contractions; intensity of contractions

It is the nurse's first meeting with a pregnant client. What is the first point that the nurse needs to ascertain as part of the admission assessment to check whether the client needs to be admitted?

Whether the client is in true or false labor.

A nurse is assigne to conduct an admission assessment on the phone for pregnant client. Which of the following information should the nurse obtain from the client? (Select all)

Estimated due date; characteristics of contractions; appearance of vaginal blood

A nurse is caring for a pregnant client who is in the active phase of labor. At what intervals should the nurse monitor the client's vital signs?

Every 30 minutes

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the FHR with the Doppler at least how often?

Every hour

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

External electronic fetal monitoring