High-Risk Intrapartum chapter 9 NCLEX book

the nurse in the obstetrician's office is caring for four prenatal clients with singleton pregnancies at 25 weeks' gestation. with which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? select all that apply 1. 38-year-old in an abusive relationship 2. 34-year-old whose first child was born at 32 weeks' gestation 3. 30-year-old whose baby has a two-vessel cord 4. 26-year-old with a history of long menstrual periods 5. 22-year-old who smokes 2 packs of cigarettes every day

1. 38-year-old in an abusive relationship 2. 34-year-old whose first child was born at 32 weeks' gestation 5. 22-year-old who smokes 2 packs of cigarettes every day -this client is high risk for PTL because she is over 35 years of age and in an abusive relationship -a previous preterm delivery places a client at increased risk of preterm labor -a client who smokes cigarettes is at high risk for preterm labor

To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which of the following medications? 1. Antacids. 2. Tranquilizers. 3. Antihypertensives. 4. Anticonvulsants.

1. Antacids. Antacids are routinely administered pre-surgically to cesarean section clients.

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. 1. Breech presentation. 2. vertex presentation at -3 Station. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.

1. Breech presentation. 2. vertex presentation at -3 Station. 5. Transverse lie. - When a baby is in the breech presentation, there is increased risk of prolapsed cord because the presenting part may not fully block the cervical opening - The presenting part is floating, which increases the risk of prolapsed cord because once again, even though the baby is in vertex presentation, it is at -3 station, leaving the cervical opening unblocked. - When a baby is in the transverse lie, there is increased risk for prolapsed cord for the same reason as in the other 2 correct answers: the cervical opening is not blocked

A client who has been diagnosed with severe preeclampsia with severe features is receiving magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).

1. Calcium gluconate. The nurse must have calcium gluconate immediately available.

The nurse is triaging four full-term primigravid clients to the labor and delivery unit. The nurse requests a bedside consultation by the primary healthcare provider for which of the clients? The client who has: Select all that apply. 1. Cervical cerclage. 2. FH 156 with beat-to-beat variability. 3. Maternal blood pressure of 90/60. 4. Full effacement. 5. Active herpes simplex 2

1. Cervical cerclage. 5. Active herpes simplex 2 -Cervical cerclage, a stitch encircling the cervix, does not rule out a vaginal delivery, but the cerclage must be removed by the provider before active labor begins -Active herpes simplex 2 is an absolute indicator for a cesarean delivery.

A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.

1. Confusion, drowsiness, and vomiting. These are the classic signs of water intoxication.

A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sadness 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.

1. Crying and sadness The nurse would expect the client to be crying and sad.

A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.

1. Diarrhea and back pain. A common side effect of Cytotec (misoprostol) is diarrhea and labor contractions are often first felt in the back.

The charge nurse is monitoring the progress of four women who are in labor. The nurse is aware that which clients will likely need a cesarean delivery? Select all that apply. 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Fetus has been diagnosed with meningomyelocele. 4. Client is hepatitis B surface antigen positive. 5. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5:1.

1. Fetus is in the left sacral posterior position. 3. Fetus has been diagnosed with meningomyelocele. 1. The baby in the LSP position is in a breech presentation. Most breech babies are delivered by cesarean section. 3. The meningomyelocele sac could easily rupture during a vaginal delivery. When a fetus has been diagnosed with the defect, a cesarean is usually performed.

101. A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.

1. Hepatitis B. 4. Group B streptococcus. 5. HIV/AIDS. 1. The client's hepatitis B status should be assessed. 4. The client's group B streptococcus status should be assessed. 5. The client's HIV/AIDS status should be assessed.

A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.

1. Intermittent fetal heart auscultation. 2. Vaginal examination. -Intermittent fetal heart aucultation is not appropriate at this time. with ruptured membranes for more than 18 hours, this client is at risk of chorioamnionitis and the fetus should be monitored continuously for signs of infection such as tachycardia -Vaginal examination is contraindicated.

A fetus is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. Dorso-superior 4. ROP (right occiput posterior).

1. LMA (left mentum anterior). LMA position is consistent with the information in the stem. the chin (mentum) is anterior, in the left upper quadrant. the fetal head is hyperextended far enough that the back of the baby's head (the occiput) is in contact with the fetal spine as we would be if standing and looking straight up at the ceiling.

The nurse is caring for a laboring woman who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1. Late decelerations. 2. Hyperthermia. 3. Hypotension. 4. Early decelerations.

1. Late decelerations. This fetus is high risk for the development of late fetal heart decelerations.

A client at 32 weeks' gestation is contracting every 3 min with each contraction lasting 60 sec. She is receiving magnesium sulfate intravenously by pump. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.

1. Low urinary output. The urinary output should be carefully monitored.

A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes +1. 4. Blood pressure 140/90.

1. Pink-tinged urine. This client's prolonged PT and PTT put her at high risk of disseminated intravascular coagulation (DIC). The nurse should watch for pink-tinged urine.

The primary healthcare provider has ordered oxytocin (Pitocin) for induction for 4 clients. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes mellitus (T1DM)

1. Primigravida with a transverse lie. Induction is contraindicated in transverse lie.

31. Immediately after a client's membranes rupture spontaneously, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

1. Put the client in the knee-chest position. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings. -The first action the nurse should take is to place the woman in the knee-chest, or trendelenburg position. -Oxygen should be administered -the primary healthcare provider should be notified immediately

9.A client at 38 weeks' gestation with hypertension and oligohydramnios is being induced with IV oxytocin (Pitocin). She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain. the nurse notices significant fetal hart rate bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

1. Turn off the oxytocin infusion. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip.

a client with an obstetrical history of G2 P1001 has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 145 bpm with moderate variability, contractions every 5 minutes X 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? 1. check the dilation and effacement 2. prepare the client for surgery 3. place the bed in Trendelenburg position 4. check the biophysical profile results

1. check the dilation and effacement it is appropriate for the nurse to assess the client's dilation and effacement

a nurse has been assigned to circulate during a cesarean section for triplets. which of the following actions should the nurse take before the birth of the babies? select all that apply 1. count the number of sterile sponges 2. document the time of the first incision 3. notify the pediatric or neonatal staff 4. perform a sterile scrub on the client 5. assemble the sterile instruments

1. count the number of sterile sponges 2. document the time of the first incision 3. notify the pediatric or neonatal staff 4. perform a sterile scrub on the client the circulating nurse should participate with the surgical technician or scrub nurse in counting the sterile sponges and writing this number on the designated board for all in the room to refer to. the circulating nurse is responsible for maintaining a clear visual record of additions and totals when more sponges and needles are added to the count throughout the procedure. -the circulating nurse must also document on the designated board and in the medical record all key events that occur during the surgery, including the time of the first incision. this time is obtained from the anesthesia provider. - the circulating nurse should notify the pediatric staff in advance, allowing them time to set up for possible resuscitations. there should be one resuscitation team assembled in the delivery room for each baby that will be delivered. each team must have appropriate equipment and personnel to care for the newborn they are responsible for -the circulating nurse must perform a surgical site scrub on the client using sterile gloves and sterile solution before the procedure

A client at 38 weeks' gestation is in labor and delivery with a painful, board-like abdomen. which of the following assessments is appropriate at this time? 1. fetal heart rate 2. cervical dilation 3. white blood cell count 4. maternal lung sounds6y7

1. fetal heart rate a fetal heart check is the appropriate assessment

A client has been diagnosed with a hypercoagulability syndrome (thrombophilia) which of the following medications would the nurse expect the primary healthcare provider to order? 1. heaprin 2. warfarin 3. Amniocapronic acid 4. DDAVP (desmopressin acetate)

1. heparin the nurse would expect the primary healthcare provider to order heparin.

A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diagnosis of acute oligohydramnios. The nurse must carefully observe this client for signs of which of the following? 1. variable FHR decelerations 2. Late FHR 3. Oliguria 4. Tachysystole

1. variable FHR decelerations 2. Late FHR -the nurse should carefully monitor the client for variable fetal heart rate decelerations -the nurse should carefully monitor the client for late decelerations in the fetal heart rate

the fetal heart rate pattern of a client in active labor shows moderate variability with late decelerations. the nurse makes which of the following interpretations of the pattern? 1. category I pattern requiring tocolytic medication administration 2. Category II pattern requiring lateral positioning, oxygen administration via face mask, and intravenous fluid bolus 3. category III pattern requiring lateral positioning, oxygen administration via face mask, intravenous fluid bolus, and amnioinfusions 4. Category IV pattern requiring immediate termination of labor

2. Category II pattern requiring lateral positioning, oxygen administration via face mask, and intravenous fluid bolus this is a category II pattern. although there are late decelerations, the variablility is moderate, indicating adequate fetal oxygenation at this time. In an attempt to correct the deceleration pattern, lateral positioning, administration of oxygen via face mask, and an intravenous fluid bolus should all be done.

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 10 milliunits per minute. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4°F.

2. Change in fetal heart rate from 128 to 102 bpm. The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin be stopped.

40. A client's assessments reveal that she is 4 cm dilated and 90% effaced with a fetal heart tracing showing frequent late decelerations 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? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.

2. Delivery of a healthy baby. The nurse's goal at this point must be the delivery of a healthy baby.

The nurse understands that a client undergoing an emergency cesarean section is likely experiencing a great deal of anxiety. Which of the following nursing interventions would be appropriate for this client? 1. Apply antiembolic boots bilaterally. 2. Explain all procedures slowly and carefully. 3. Administer an antacid per MD orders. 4. Monitor the FHR and maternal vital signs.

2. Explain all procedures slowly and carefully. The nurse should explain all procedures slowly and carefully. An emergency cesarean section is often very traumatic for a client who had anticipated a vaginal birth. she worries not only about her own safety and the threat of surgery, but also about the baby's survival. As a result, she may not be able to understand everything that is said at the time and needs calm reassurance as much as possible.

A doctor orders a narcotic analgesic for a laboring client. In which of the following situations is it essential for the nurse to hold the medication and not administer it? 1. Contraction pattern is every 3 min × 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.

2. Fetal monitor tracing shows late decelerations. Late decelerations are indicative of uteroplacental insufficiency and indicate fetal distress. It is inappropriate to administer a central nervous system (CNS) depressant to the mother at this time.

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2. Flex the woman's thighs sharply toward her abdomen. Flexing the woman's hips sharply toward her abdomen, called McRobert's maneuver, is appropriate.

A client at 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.

2. Follow standard infectious disease precautions. -Standard precautions are indicated in this situation.

While waiting to conclude the third stage of labor, the obstetrician states that a client has placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.

2. Hemorrhage. The nurse would expect the client to hemorrhage.

A physician has notified the labor and delivery suite that four clients will be admitted to the unit. The client with which of the following clinical findings would be a candidate for an external version? 1. +3 station. 2. Left sacral posterior position. 3. Flexed attitude. 4. Rupture of membranes for 24 hours.

2. Left sacral posterior position. LSP position is a breech presentation. It may be appropriate for a physician to perform an external version prior to this delivery.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 120 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.

2. Maternal temperature Maternal temperature is the highest priority.

The physician has ordered Prepidil (dinoprostone) for four clients at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. G1 P0000 contracting every 20 minutes × 30 seconds. 4. G6 P3202 with blood pressure 140/90 and pulse 92.

2. Multigravida with late decelerations. Dinoprostone is not appropriate for this client. this client's fetus is already showing signs of fetal hypoxemia, as evidenced by late decelerations. an induction is contraindicated, as it would increase the risk of injury by reducing available oxygen with each contraction. this client will likely need a cesarean section.

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? 1. Encourage the client to breathe with contractions. 2. Notify the primary healthcare provider 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.

2. Notify the primary healthcare provider Sinusoidal patterns are related to Rh isoimmunization, fetal anemia, severe fetal hypoxia, or a chronic fetal bleed. They also may occur transiently as a result of Demerol (meperidine) or Stadol (butorphanol) administration. As this client has just been admitted, medication administration is not a likely cause. The health care practitioner should be notified.

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the primary healthcare provider of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.

2. Notify the primary healthcare provider of her request. The nurse should notify the health care provider of the client's request.

The nurse observes a new staff member caring for an eclamptic client following a seizure. which of the following actions by the staff member indicates an understanding of eclampsia? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2. Pad the client's bed rails and headboard. The side rails of an eclamptic client's bed should be padded.

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.

2. Petechiae. 3. Jaundice. -Petechiae may develop when a client is thrombocytopenic, one of the signs of HELLP syndrome. -Hyperbilirubinemia develops when red blood cells hemolyze, one of the changes that may develop as a result of liver necrosis. Jaundice is a manifestation of hyperbilirubinemia.

The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following conditions is the client at risk for at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.

2. Risk for fetal injury related to possible intrauterine hypoxia. Green amniotic fluid in the presence of recurrent late decelerations suggests fetal stress due to intrauterine hypoxia

A physician writes the following order—Administer ampicillin G, 5 million units IV x 1, then 2.5 million units q 4 h until delivery—for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal (GBS) bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacterium is sexually transmitted. 4. The bacterium causes puerperal sepsis.

2. The baby is at high risk for neonatal sepsis. Babies are susceptible to neonatal sepsis from vertical transmission of the bacteria.

An oxytocin induction of a client at 42 weeks' gestation is started at 0900 at a rate of 2 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal intolerance of labor has been noted when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.

2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. The standard care is to increase the dosage of oxytocin at a minimum time interval of every 30 minutes, not every 10 minutes

The nurse is monitoring a woman, G2 P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; -3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; -3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1. Labor is progressing well. 2. The woman is likely carrying a macrosomic fetus. 3. The fetus is not tolerating labor 4. The woman will be in second stage in about five hours.

2. The woman is likely carrying a macrosomic fetus. Because the presenting part is not descending into the birth canal, the nurse can logically conclude that the baby is macrosomic.

which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor? 1. client will be infection free at discharge 2. client will exhibit normal breathing function at discharge 3. client will exhibit normal gastrointestinal function at discharge 4. client will void without pain at discharge

2. client will exhibit normal breathing function at discharge because ASP begins in the lungs, the appropriate nursing care outcome is that the client survives and is breathing normally at discharge

the nurse notes a pattern of tachysystole during a client's oxytocin induction. the nurse turns off the oxytocin infusion. which of the following outcomes indicates that the nurse's action was effective? 1. contraction intensity moderate 2. contraction frequency every 3 minutes 3. fetal heart rate 140 bpm4 4. fetal attitude flexed

2. contraction frequency every 3 minutes a frequency pattern of every 3 minutes is ideal

In which of the following clinical situations would amnioinfusion be appropriate? 1. placental abruption 2. meconium-stained fluid 3. polyhydramnios 4. late decelerations

2. meconium-stained fluid it would be appropriate for a primary healthcare provider to order an amnioinfusion when a client's amniotic fluid is meconium stained.

A laboring client who has developed an apparent anaphylactic syndrome of pregnancy (ASP) response is not breathing and has no pulse. In addition to calling a code, which of the following actions by the nurse, who is alone with the client, is appropriate at this time? 1. perform cardiac compressions and breaths in a 15 to 2 ratio 2. provide chest compressions at a depth of at least 2 inches 3. compress the chest at the lower 1/2 of the sternum 4. provide rescue breaths over a 10-second time frame

2. provide chest compressions at a depth of at least 2 inches chest compressions should be delivered at a depth of at least 2 inches and no more than 2.4 inches

the nurse is caring for a client at 30 weeks' gestation whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. how to use a blood glucose monitor 2. signs of preterm labor 3. signs of pre-eclampsi 4. how to do fetal kick count assessments

2. signs of preterm labor positive fetal fibronectin levels are seen in clients who deliver preterm

A client at 40 2⁄7 weeks' gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units oxytocin (Pitocin) to be diluted in 1,000 mL D51⁄2 NS. The order reads: Administer oxytocin IV at 0.5 milliunits per min. Calculate the drip rate for the infusion pump to be programmed. Please calculate to the nearest whole number. __________ mL/hr.

3 mL/hr.

Three clients at 30 weeks' gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A client with cardiac disease. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order.

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 intrapartum complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta.

3. Abruptio placentae. Placental abruption is associated with maternal illicit drug use.

44. A 35-year-old client with pre-eclampsia is being induced with oxytocin (Pitocin) is contracting every 3 minutes, with each contraction lasting 30 seconds. Suddenly the woman becomes dypsneic and cyanotic, and begins to have chills. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.

3. Administer oxygen. The nurse's priority action is to administer oxygen, which will treat both the mother and the fetus

19. There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3 P0020, in active labor. 2. Age 22, G1 P0000, eclampsia. 3. Age 25, G4 P3003, last delivery by cesarean section. 4. Age 32, G2 P0100, first baby died during labor.

3. Age 25, G4 P3003, last delivery by cesarean section. Any client who has had a previous cesarean section is at risk for uterine rupture.

A client has been in the second stage of labor for 21/2 hours. The fetal head is at +4 station and the fetal heart is showing recurrent late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the woman to push between contractions. 3. Assess the fetal heart rate after each contraction. 4. Advise the woman to refuse the use of forceps.

3. Assess the fetal heart rate after each contraction. The FHR should always be assessed continuously in this situation with recurrent late decelarations. the FHR indicates fetal hypoxemia and possible hypoxia

A client, 39 weeks' gestation, fetal heart baseline at 145 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman's bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman's uterus and monitor for ballottement.

3. Assess the fluid with nitrazine and see if the paper turns blue. The fluid should be assessed with nitrazine paper.

A 30-year-old client with an obstetrical history of G2 P0010 is in preterm labor. She is receiving nifedipine (Procardia). Which of the following maternal assessments noted by the nurse must be reported to the health care provider immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2,000 mL.

3. Audible rales. Audible rales should be reported to the health care provider.

The nurse is assessing the Bishop score on a client who is postdates. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.

3. Cervical dilation. 4. Fetal station. 5. Cervical position. -Cervical dilation is part of the Bishop score. -Fetal station is part of the Bishop score. -Cervical position is part of the Bishop score.

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 findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.

3. Cord compression. The contractions described in the scenario result from cord compression (variable decelerations).

A nurse is caring for a primiparous client at 35 weeks' gestation. the client is having uterine contractions. which of the following confirms that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.

3. Dilation 3 cm. 4. Cervical length of 2 cm. -The dilation of 3 cm is indicative of preterm labor. -A cervical length of 2 cm is indicative of preterm labor.

The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. clients with spinal anesthesia complain of nausea and vomiting.

3. Epidurals do not fully sedate motor nerves. Epidurals do not fully sedate the motor nerves of the client. Epidural clients are capable of moving their lower extremities even when fully pain free.

the primary healthcare provider for a client at 38 1/7 weeks' gestation calls the labor and delivery suite to schedule an induction for the next day. the client is having no medical or pregnancy complications. which of the following responses by the nurse would be appropriate? 1. at what time would you like to begin the induction 2. what is the client's Bishop score 3. I am sorry but the client will not be able to be induced tomorrow 4. I will have the prostaglandin induction medication prepared

3. I am sorry but the client will not be able to be induced tomorrow the nurse should remind the provider of the policy that does not allow elective inductions to be scheduled before 39 weeks' gestation

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min × 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

3. Magnesium sulfate. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time to stop or reduce the strength and frequency of the labor contractions

During the delivery of a macrosomic baby, a client developed a fourth-degree laceration. the nurse has just reviewed with the client, the provider's education about the laceration. which comment by the client indicates she understands the extent of her lacerations 1. my laceration extended Into the muscles around my anus. 2. my laceration extended into my urinary meatus where I pee. 3. My laceration extended through my rectal sphincter into my rectum. 4. My laceration extended up to my clitoris.

3. My laceration extended through my rectal sphincter into my rectum. a fourth-degree laceration extends through the rectal sphincter into the rectum

A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.

3. Palpate bladder. The client's bladder should be palpated.

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Platelets 75,000. Low platelets are consistent with the diagnosis of HELLP syndrome.

30. Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with moderate variability and early decelerations. Immediately following the procedure, the tracing shows a fetal heart rate of 120 with a prolonged deceleration. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta.

3. Prolapsed cord. The drop in fetal heart rate with variable decelerations indicates that the cord has likely prolapsed.

A charge nurse is working with four nurses new to the obstetrical unit. during their shift, the fetal heart rate patterns on all four fully dilated clients shows minimal variability and late decelerations. the primary healthcare providers all request forceps to speed the deliveries. in which of the situations should the nurses be advised to refuse to provide the delivery forceps? select all that apply. 1. Maternal history of asthma. 2. Right occiput posterior position at +4 station. 3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute at -1 station. 5. Maternal history of cerebral palsy.

3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute at -1 station. -A baby in transverse lie is physically incapable of delivering vaginally and must be delivered by cesarean section. -It is not appropriate to deliver a baby with forceps for two reasons: (a) the baby is in a mentum position. the baby is not flexed, and the chin is presenting; (b) in addition, the fetus at -1 station is not engaged. forceps are contraindicated for a fetus that is not low in the pelvis, regardless of the presenting part, even if the fetus is in the vertex position.

A client with pre-eclampsia with severe features at 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. duration of contractions of 130 seconds 4. Fetal heart rate 155 with early decelerations.

3. duration of contractions of 130 seconds The duration of the contractions is prolonged. We don't know how frequently the contractions are coming, but each one is lasting 2 minutes and 10 seconds. this is called a tetanic contraction. The baby is deprived of oxygen through most of the contraction, since there is no oxygen-rich blood flow to the intervillous space for placental uptake during the peak of this long contraction

A client with an internal fetal spiral electrode in place has just received an IV narcotic for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. minimal variability 4. Accelerations after contractions.

3. minimal variability minimal variability would be expected as a result of narcotic administration

a client who is hepatitis B surface antigen positive is in active labor. which action by the nurse is appropriate at this time? 1. obtain an order from the obstetrician to prepare the client for cesarean deliveryterm-21 2. obtain an order from the obstetrician to administer intravenous penicillin during labor and the immediate postpartum 3. obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth 4. obtain an order from the pediatrician to place the baby in isolation after delivery

3. obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG (hepatitis B immune globulin)

A client whose fetus is exhibiting signs of erythroblastosis is admitted to the labor and delivery unit. the nurse would expect to see which of the following fetal heart rate monitor tracings? 1. marked fetal heart rate variability 2. prolonged fetal heart rate accelerations 3. sinusoidal fetal heart rate pattern 4. periodic variable decelarations

3. sinusoidal fetal heart rate pattern the nurse would expect to see a sinusoidal fetal heart rate pattern

After a multiparous client has been in active labor for 15 hours, an ultrasound is done. The results show that the obstetric conjugate is 10 cm and the suboccipitobregmatic diameter is 10.5 cm. which of the following labor findings is related to these results? 1. full dilation of the cervix 2. full effacement of the cervix 3. station of -3 4. frequency every 5 minutes

3. station of -3 a high station is consistent with the data in the scenario

a client at 40 weeks' gestation with an obstetrical history of G3 P2002 has just been admitted in early labor. she has vaginal candidiasis. which of the following should the nurse advise the client about? 1. she may need a cesarean delivery 2. she will be treated with antibiotics during labor 3. the baby may develop thrush after delivery 4. the baby will be isolated for at least one day

3. the baby may develop thrush after delivery Thrush is the term given to oral candidiasis, which the baby may develop after delivery

Five minutes ago, the primary healthcare provider performed an amniotomy (ruptured the client's membranes) on a client at 40 weeks' gestation. The client's obstetrical history is G3 P1011. The fetus was at -4 station, and ROP position at the time of the amniotomy. the fetal heart rate is now 140 bpm with a prolonged deceleration. the fluid is green tinged. the nurse concludes that which of the following situations is present at this time? 1. the fetus is post-term 2. the presentation is breech 3. the cord is prolapsed 4. the amniotic fluid is infected

3. the cord is prolapsed the prolonged deceleration indicates the cord is prolapsed. this is likely because the amniotomy was performed when the presenting part was at -4 station, not yet engaged.

a preterm labor client at 30 weeks' gestation reported rupture of membranes 4 hours ago. this was confirmed on examination. the nurse prepares to administer IM dexamethasone. When the client asks why she is receiving the drug, the nurse replies: 1. to help to stop your labor contractions 2. to prevent an infection in your uterus 3. to help to mature your baby's lungs 4. to decrease the pain from contratctions

3. to help to mature your baby's lungs Dexamethasone is a steroid that hastens the maturation of the fetal lung fields

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual odor." 3. "Your labor should start very soon." 4. "Have you felt the baby move since the membranes broke?"

4. "Have you felt the baby move since the membranes broke?" -The most important information needed by the nurse should relate to the health and well-being of the fetus. Fetal movement indicates that the baby is alive.

A nurse is triaging four clients on the labor and delivery unit. Which of the following actions should be a priority for nursing care? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.

4. Check the fetal heart rate of a client who just ruptured membranes. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency.

A nurse administers magnesium sulfate via infusion pump to a laboring client who has pre-eclampsia. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output is 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.

4. Client has no grand mal seizures. The absence of seizures is an expected outcome related to magnesium sulfate administration.

A client with an obstetrical history of G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.

4. Contraction frequency of 1 minute. A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication.

A client at 4o weeks' gestation has an admitting platelet count of 90,000 cells/mm3 and a hematocrit of 29%. Her lab values 1 week earlier were platelet count 200,000 cells/mm3 and hematocrit 37%. Which additional abnormal lab value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).

4. Elevated alanine transaminase (ALT). The nurse would expect to see an elevated alanine aminotransaminase (ALT).

The nurse notes that the fetus of a laboring client is exhibiting signs of fetal intolerance of labor. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.

4. Increase the intravenous infusion rate. Increasing the IV rate helps to improve perfusion to the placenta.

A client with an obstetrical history of G1 P0000 received dinoprostone for cervical ripening 8 hours ago. The Bishop score at that time was 4. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place woman on her side. 4. Monitor for onset of labor.

4. Monitor for onset of labor. The nurse should monitor this client for the onset of labor.

A client with an obstetrical history of G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give oxygen via face mask 3. Change the client's position. 4. Monitor the client's labor.

4. Monitor the client's labor. It is appropriate to monitor the woman's labor.

37. A client with an obstetrical history of G3 P2002 is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The client's doctor informs her that the baby must be delivered by cesarean section. The client refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.

4. Provide the woman with ongoing labor support. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 10 g/dL.

4. Serum magnesium level of 10 g/dL. A serum magnesium level of 10 g/dL is dangerously high. The magnesium sulfate should be turned off and the primary healthcare provider should be notified immediately. the client's respiratory rate should be counted, as the client is at high risk of respiratory depression. a bad and mask should be available if needed before the calcium gluconate antidote can be administered or before it takes effect

Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia Shoulder dystocia is an obstetric emergency.

A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).

4. Terbutaline (Brethine) Terbutaline (Brethine) is a smooth, muscle-relaxing agent. It would be administered prior to an external version to relax the uterus and prevent contractions

A client with an obstetrical history of G3 P2002 has just had an external version. The nurse monitors this client carefully for which of the following? 1. Decreased urinary output. 2. Elevated blood pressure. 3. Severe occipital headache. 4. Variable fetal heart decelerations.

4. Variable fetal heart decelerations. The nurse should monitor the client carefully for variable fetal heart decelerations.

Four women request to labor in the hospital bathtub with waterproof fetal heart rate (FHR) monitoring devices. In which of the following situations is this contraindicated? Select all that apply. 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with meconium-stained fluid. 5. Woman with fetus in the occiput posterior position.

4. Woman with meconium-stained fluid. 5. Woman with fetus in the occiput posterior position. -Meconium-stained amniotic fluid may indicate fetal distress. Continuous electronic fetal monitoring would, therefore, be indicated. -the warm water in the bath may increase the woman's temperature, leading to an increased FHR and fetal tachycardia. as such, a water bath is contraindicated for a client with a temp of 100.4 F (38 C) or above.

A client at 42 weeks' gestation with an obstetrical history of G3 P2002 is admitted to the labor suite for induction. A biophysical profile (BPP) report on the client's chart indicates a BPP score of 6 out of 10. The nurse should monitor this client carefully for which of the following? 1. maternal hypertension 2. maternal hyperglycemia 3. increased fetal heart variability 4. a fetal heart-rate pattern of late decelerations

4. a fetal heart-rate pattern of late decelerations the fetal heart rate pattern is likely to show late decelerations secondary to a postmature placenta

a client is scheduled to have an external version for a breech presentation. the nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. station -2 2. 38 weeks' gestation 3. reactive nonstress test (NST) 4. previous cesarean section

4. previous cesarean section previous cesarean section is a contraindication for external version

A client is in active labor. Which of the following assessments would warrant immediate intervention? 1. Maternal PaCO2 of 40 mm Hg. 2. Alpha-fetoprotein values of 2 times normal. 3. 3 fetal heart accelerations during contractions. 4. recurrent late decelerations with minimal variability

4. recurrent late decelerations with minimal variability recurrent late decelerations with minimal variability indicate a fetus who is struggling to maintain adequate oxygenation and is at risk of metabolic acidosis. the primary healthcare provider must be notified immediately and the nurse must implement appropriate interventions such as administering oxygen, an intravenous bolus of lactated ringer's solution, and changing the maternal position immediately

An anesthesiologist informs the nurse that a client scheduled for cesarean section will have the procedure under general anesthesia rather than regional anesthesia. Which of the following would warrant this decision? 1. the client has a history of drug addiction 2. the client is allergic to morphine sulfate 3. the client is a 13-year-old adolescent 4. the client has had surgery for scoliosis

4. the client has had surgery for scoliosis a history of scoliosis surgery is a contraindication for spinal anesthesia

a pregnant client with an obstetrical history of G3 P2002 had her two pervious children by cesarean section. she would like to have a vaginal birth this time and requests a trial of labor after cesarean section (TOLAC). which of the following situations would exclude a TOLAC and mandate that this delivery also be by cesarean? 1. the client refuses to have a regional anesthesia 2. the client is postdates with intact membranes 3. the baby is in the occiput posterior position 4. the previous uterine incisions were vertical

4. the previous uterine incisions were vertical the presence of vertical incisions in the uterine wall is an absolute indication for a cesarean delivery

A nurse is monitoring a client who is receiving an amnioinfusion. which of the following assessments is critical for the nurse to make to prevent a serious complication related to the procedure? 1. color of the amniotic fluid 2. maternal blood pressure 3. cervical effacement 4. uterine resting tone

4. uterine resting tone the uterine resting tone should be carefully monitored with an intrauterine pressure catheter (IUPC) during amnioinfusion

A client with insulin-dependent diabetic is in active labor. The physician has written the following order: Administer regular insulin 5 units per hour via IV pump. The insulin has been diluted as follows: 50 units/500 mL normal saline. At what rate should the nurse set the pump? Please calculate to the nearest whole number. __________ mL/hr.

50 mL/hr