CMCA LEC

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: 1 cm above the ischial spine 1 fingerbreadth below the symphysis pubis 1 inch below the coccyx 1 inch below the iliac crest

1 cm above the ischial spine

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? Three contractions occurring within a 10-minute period Increased urinary output Adequate resting tone of the uterus palpated between contractions Increased urinary output (A fetal heart rate of 90 beats per minute, wala sa choices sa quiz)

A fetal heart rate of 90 beats per minute

A laboring client is in the first stage of labor and has progressed in cervical dilation from 4 to 7cm. Which of the following phases of the first stage has the most rapid cervical dilation? Preparatory phase Latent phase Active phase Transition phase

Active phase

A nurse in the labor room attends to a client in the active phases of labor. The nurse is evaluating fetal patterns when she notices alate deceleration an the monitor strip. The best nursing intervention is to: Administer oxygen via face mask Increase the rate of Pitocin IV infusion Document the findings and continue to monitor the fetal patterns Place the mother in the supine position

Administer oxygen via face mask

In early active labor, a client is admitted to the birthing suite. This client's priority nursing intervention upon admission would be: Auscultating the fetal heart Taking an obstetric history Asking the client when she last ate Ascertaining whether the membranes were ruptured

Auscultating the fetal heart

A client in labor who is gravida 1, para O is admitted. Her cervix is 100% effaced, and she is 3cm dilated. Her fetus is at station +1. The nurse notices that the fetus's head Not yet engaged Entering the pelvic inlet Below the ischial spines Visible at the vaginal opening

Below the ischial spines

As the fetus' head escrowing, othermother should be instructed to use which of the following breathing technique? Blowing Slow chest Shallow Accelerated-decelerated

Blowing

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? The umbilical cord grows shorter and changes color A soft and boggy uterus Maternal complaints of severe uterine cramping Changes in the uterus's shape

Changes in the uterus's shape

A multiparous client who has been in labor for two hours reports feeling the need to move her bowels. What should the nurse do? Allow the client to get up to use the restroom Examine the fetal heartrate Conduct a pelvic examination Permit the client to use a bedpan

Conduct a pelvic examination

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? Placing a code cart near the client's bedside Complete bed rest for the client An antibiotic IV infusion Continuous electronic fetal monitoring

Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.

A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? Every 5 minutes Every 15 minutes Every 30 minutes Every 60 minutes

Every 15 minutes

The nurse records "50%, 6 cm, - 1" after completing a vaginal examination on a laboring woman. Which of the following data interpretations is CORRECT? Dilation is 50% completed Effacement is 4 cm from completion Fetal presenting part is 1 om above the ischial spines Fetus has achieved passage through the ischial spines

Fetal presenting part is 1 om above the ischial spines

A nurse assists with the vaginal delivery of a newborn infant in a labor room. If which of the following occurred, the nurse would closely monitor the client for the risk of uterine rupture? Hypotonic contractions Forceps delivery Schultz delivery Weak bearing down efforts

Forceps delivery

The multigravida other in active labor with a history of rapid labor who is inactive labor exclaims to the nurse, "The baby is coming!" Which of the following actions would the nurse take first? Time the contractions Inspect the perineum Contact the birth attendant Auscultate the fetal heartrate

Inspect the perineum

The nurse examines the client's amniotic fluid and determines that it is normal because: It has a clear and dark amber color It is milky, greenish yellow, containing shreds of mucus It is clear, almost colorless, and containing little white specks It is cloudy, greenish-yellow, and containing little white specks

It is clear, almost colorless, and containing little white specks

While the client is in active labor with twins and the cervix is 5cm dilated, the nurse observes contractions occurring at a rate of every 7to 8minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? Note the fetal heart rate patterns Notify the physician immediately Administer oxygen at 6 liters by mask Have the client pant-blow during the contractions

Notify the physician immediately

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3minutes that last 45seconds.The nurse notes that the fetal heart rate between contractions is 100BPM. Which of the following nursing actions is most appropriate? Encourage the client to continue pushing with each contraction Notify the physician or nurse mid-wife Continue monitoring the fetal heart rate Encourage the client's coach to continue to encourage breathing exercises

Notify the physician or nurse mid-wife

A nurse is monitoring a client in active labor and notices that the client is having 45 second contractions every 3 minutes. According to the notes of the nurse, the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is the MOST APPROPRIATE? Continue monitoring the fetal heart rate Encourage the client's coach to keep promoting breathing exercises Encourage the client to push harder with each contraction Notify your doctor or nurse midwife

Notify your doctor or nurse midwife

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: Breech Transverse Occiput anterior Occiput posterior

Occiput anterior

Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors? Contractions, passageway, placental position and function, pattern of care Contractions, maternal response, placental position, psychological response Passageway, contractions, placental position and function, psychological response Passageway, placental position and function, paternal response, psychological response

Passageway, contractions, placental position and function, psychological response

A nurse assists in the vaginal delivery of a newborn infant. The nurse notices the umbilical cord lengthening and a spurt of blood from the vagina after the delivery. The nurse documents these observations as signs of: Hematoma Placenta previa Placental separation Uterine atony

Placental separation

Perineal care is an important infection prevention strategy. The nurse would recognize the need for additional instruction when evaluating a postpartum woman's perineal care technique if the woman: Rinses her vagina upward with the peri bottle. Washes the vulva and perineum with soap and warm water. Washes from the pubis to the episiotomy Changes her perineal pad every 2 - 3 hours

Rinses her vagina upward with the peri bottle.

A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: Transfer her immediately to the birthing unit on a stretcher. Tell her not to bear down and to breathe through her mouth. Instruct the client to pant and breathe through her mouth during contractions. Support the perineum with a hand and instruct the client to pant to prevent tearing

Support the perineum with a hand and instruct the client to pant to prevent tearing

A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? The contractions are regular. The client starts leaking clear vaginal fluid. The membranes have ruptured. The cervix has completely dilated.

The cervix has completely dilated.

Which of the following descriptions BEST describes fetal presentation? The first fetal body part to enter the maternal pelvis A classification based on the fetal part The presenting part's relationship to the maternal pelvis Relationship of the fetus's long axis to the mother's long axis

The first fetal body part to enter the maternal pelvis

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: Until it is completely finished To the end of a second contraction To the start of the next contraction Until the uterus becomes very firm

To the start of the next contraction

During the induction of labor, a client should be closely monitored for signs of: Severe pain Uterine tetany Hypoglycemia Umbilical cord prolapse

Uterine tetany

Which of the following fetal positions is MOST FAVORABLE to childbirth? Transverse lie Vertex presentation Frank breech presentation Posterior position of the fetal head

Vertex presentation