Intra

A client, who is 7cm dilated and 100% effaced, is breathing at a rate of 30 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers with some lightheadedness. Which of the following actions should the nurse take at this time?

Have the woman breathe into a bag

A women who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuble information regrading the client's labor status?

Vaginal examination

A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used.

increment, acme, decrement, relaxation

The nurse teaches a client that lightening occurs about 2 weeks before the onset of labor. What will the mother most likely experience at that time?

Urinary frequency

A full term client, contracting every 15 minutes for 30 seconds, has had ruptured membranes for 20 hours. Which of the following nursing interventions are contraindicated at this time?

Vaginal examination

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform?

Give the mother a back rub

The nurse is assessing the Bishop score on a client. Which of the following measurements will the nurse assess? Select all that apply.

. ▪Cervical position ▪Fetal station ▪Cervical dilation

During the induction process, a patient frequently asks, "What are you doing now?" or "What is that for?" Which nursing diagnosis is most appropriate for this patient?

.Knowledge Deficit related to induction of labor

The health care practitioner orders the following medication for a laboring client: Stadol 0.5mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2mg/ml. How many mL of medication will the nurse administer? Round to the nearest hundredth.

0.25 mL

It is 4 p.m. The client is 3cm dilated and asks the nurse when the dinner tray will be served. The best response by the nurse would be?

"A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate?

.Inform the mother that the rate is normal.

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is

2 cm

The physician writes the following order for a newly admitted client in labor: Begin a 1000mL IV of D5 1/2 NS at 150ml/hr. The IV tubing states that the drop factor is 10gtt/ml. Calculate the drip rate in gtt/min. Round to the nearest whole number.

25 gtt/min

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

Abrupto Placentae

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

Administer oxygen

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?

Age 25, last delivery by cesarean section

To reduce possible side effects from a cesarean section under anesthesia, clients are routinely given which of the following medications?

Antacids

A client states, "I think my water has broke! I felt this gush of fluid between my legs!" The nurse tests the fluid with a Nitrazine swab and confirms membrane rupture if the swab turns

Blue

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Check the fetal heart rate

A woman telephones her health care provider and reports that her water just broke. Which suggestion by the nurse would be most appropriate?

Come to the clinic or emergency department for an evaluation.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action would the nurse do next?

Continue to monitor the FHR because this pattern is not dangerous to the fetus.

A client's assessments reveal that she is 4 cm dilated and 80% 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?

Delivery of a healthy baby

A nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:

Determine the maternal and fetal vital signs

Which subjective assessment data will the nurse obtain from a patient who is being prepared for a Cesarean section?

Diet history for the past 8 hours

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following?

Drop in blood pressure

A woman with severy preeclampsia, 38 weeks gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurst to stop the infusion?

Duration of contractions of 120 seconds

A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes?

Endocervically

Which method of cervical ripening and induction of labor does the nurse consider safest and least likely to result in complications?

Insertion of a transcervical Foley catheter

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must precede this assessment?

Instert an internal fetal monitor electrode

During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate?

It's difficult to predict how your labor will progress, but we will be there for you the entire time."

A woman in her third trimester comes to the clinic for a prenatal visit. During assessment, the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event has most likely occurred?

Lightening

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time?

Maternal temperature

In which of the following clinical situations would it be appropriate for an obstetrician to order an amnioinfusion?

Meconium-stained fluid

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom?

Moderately strong contractions every 4 minutes, lasting about 1 minute.

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?

Percentage of thinning

A client is 8 cm dilated is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with an analgesic-potentiating medication. Which of the following medications would the nurse expect to be ordered as the analgesic-potentiating medication?

Phenergan (promethazine)

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

Place the client in the knee-chest position

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as?

Possible infection

A woman is scheduled to have an external cephalic 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?

Previous Cesarean birth

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

Provide the woman with ongoing labor support.

In addition to breathing with contractions, which of the following actions can help a woman in labor to work with the pain of the first stage of labor?

Receiving massage

A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?

Respiratory rate of 10 breaths per minute

The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses is appropriate at this time?

Risk for impaired skin integrity

The nurse is performing an assessment of a client progressing through labor. Place the following findings in the order in which they occur. All options must be used.

Strong braxton hicks contractions,Mild contractions lasting 20-40 seconds,Cervical dilation of 7 cm, 100% effacement,uncontrollable urge to push

A client is in labor. She was admitted 3 hours ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes, breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation?

The client is exhibiting an expected behavior for the transition phase of labor.

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?

The uterus rises upward

An immediate Cesarean section will need to be performed if the nurse assesses which signs or symptoms in a woman attempting vaginal birth after a prior Cesarean section?(Select all that apply.)

▪A popping sensation reported by the patient ▪Acute, continuous abdominal pain ▪Repetitive or prolonged fetal heart rate decelerations ▪Vaginal bleeding

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply.

▪Assess fetal heart rate ▪Infuse intravenous fluid if ordered ▪Have client empty bladder

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply.

▪Fundal height measurement ▪Membrane status ▪Contraction pattern

A nurse is caring for a client who is in the third stage of labor. Which characteristic behaviors does the nurse anticipate at this stage? Select all that apply.

▪The client states she has discomfort from uterine contractions. ▪The client is focused on the neonate's condition.