Intrapartum (Exam 3)

On exam of a full term pimipara, the nurse notes: active labor, ROA, 7cm dilated, and +3 station. Which of the following should the nurse report to the physician? A. Descent is progressing well B. Fetal head is not yet engaged C. Vaginal delivery is imminent D. External rotation is complete

A

The nurse auscultates a FHR of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? A. Inform the mother that this rate is normal B. Reassess in 5 minutes to verify the results C. Immediately report the rate to the healthcare practitioner D. Place the client on her left side and apply oxygen by face mask

A

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 bpm. What should the nurse do? A. Provide caring labor support B. Administer oxygen via face mask C. Change the client's position D. Speed up the client's IV

A

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? A. The relationship between the decelerations and the labor contractions B. The maternal BP C. The gestational age of the fetus D. The placement of the fetal heart electrode in relation to the fetal position

A

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following would be appropriate for the nurse to delegate to the doula? Select all that apply. A. Give the woman a back rub B. Assist the woman in her breathing C. Assess the FHR D. Check the woman's BP E. Regulate the woman's IV infusion rate

A, B

A client, G2P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to make at this time? A. Assess the woman's temperature. B. Place a wedge under the woman's side. C. Place a blanket roll under the woman's feet. D. Assess the woman's pedal pulses

B

A nurse describes a client's contractions pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds with this description? A. Contractions lasting 60 sec followed by a 1 min rest period B. Contractions lasting 120 sec followed by a 2 min rest period C. Contractions lasting 2 min followed by a 60 sec rest period D. Contractions lasting 1 min followed by a 120 sec rest period

D

A client in labor G2P1001 was admitted 1 hour ago at 2cm dialted and. 50% effaced. She was talkative and excited at that time. During that past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? A. The client had poor education prior to labor B. The client is exhibiting an expected behavior for labor C. The client is becoming hypoxic and hypercapnic D. The client needs her alpha-fetoprotein levels checked

B

A gravid client, G3P2002 was examined 5 minutes ago. Her cervix was 8cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? A. Offer the client the bedpan B. Evaluate the progress of labor C. Notify the physician D. Encourage the patient to push

B

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgement should be questioned if the fetal presenting part is which of the following? A. Sacrum B. Occiput C. Mentum D. Scapula

D

A woman who is in active labor is told by her OB, "your baby is in the flexed attitude." When she asks the nurse what this means, what should the nurse say? A. The baby is in the breech position B. The baby is in the horizontal line C. The baby's presenting part is engaged D. The baby's chin is resting on it's chest

D

A woman who states that she "thinks" she is in labor enters the L&D unit. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? A. Leopold maneuvers B. Fundal contractility C. Fetal heart assessment D. Vaginal exam

D

A woman, 40 weeks gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? A. "The contractions are 5-20 min apart" B. "I saw pink discharge on the toilet tissue when I went to the bathroom" C. "I have had cramping for the past 3-4 hrs" D. "The contractions are about 1 min long and I am unable to talk through them"

D

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. A. Weight gain. B. Ethnicity and religion. C. Age. D. Type of insurance. E. Gravidity and parity.

A, B, C, E

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. A. After vaginal exams. B. Before administration of analgesics. C. Periodically at the end of a contraction. D. Every ten minutes. E. Before ambulating.

A, B, C, E

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. A. Bulging perineum B. Increased bloody show C. Spontaneous rupture of membranes D. Uncontrollable urge to push E. Inability to breathe through contractions

A, B, D

A woman has just arrived at the L&D unit. To report the client's status to her primary healthcare practitioner , which of the following assessments should the nurse perform? Select all that apply. A. Fetal heart rate B. Contraction pattern C. Urinalysis D. Vital signs E. Biophysical profile

A, B, D

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. A. Assess FHR B. Infuse 1000 mL of Ringer's lactate C. Place the woman in Trendelenburg position D. Monitor the BP every 5 minutes for 15 minutes E. Have the woman empty her bladder

A, B, E

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? A. The woman has an internal laceration B. The woman is about to deliver the placenta C. The woman has an atonic uterus D. The woman is ready to expel the cord bloods

B

During a vaginal exam, the nurse palpates fetal buttocks that are facing the left posterior and are 1cm above the ischial spines. Which of the following is consistent with this assessment? A. LOA -1 station B. LSP -1 station C. LMP +1 station D. LSA +1 station

B

Immediately following administration of an epidural, the nurse must monitor the mother for which of the following side effects? A. Paresthesias in her feet and legs B. Drop in BP C. Increase in central venous pressure D. Fetal heart accelerations

B

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? A. She is contracting q 5 min x 60 sec B. Her cervix has dilated from 2-4cm C. Her membranes have ruptured D. The fetal head is engaged

B

The nurse is assessing an internal fetal heart rate monitor tracing of an unmedicated, full term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? A. Baseline of 140-150 with V-shaped decelerations to 120 unrelated to contractions B. Baseline of 140-150 with decelerations to 100 that mirror each of the contractions C. Baseline of 140-142 with decelerations to 120 that return to baseline after the end of the contraction D. Baseline of 140-142 with no obvious decelerations or accelerations

B

The nurse is assessing the fetal station during a vaginal exam. Which of the following structures should the nurse palpate? A. Sacral promontory B. Ischial spines C. Cervix D. Symphysis pubis

B

The nurse wishes to assess the variability of the FHR. Which of the following actions must the nurse perform at this time? A. Place the client in the lateral recumbent position B. Carefully analyze the baseline data on the monitor tracing C. Administer oxygen to the mother via face mask D. Ask the mother to indicate when she feels fetal movement

B

A nurse has just performed a vaginal exam on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? A. LUQ B. LLQ C. RUQ D. RLQ

C

A woman is in active labor and is being monitored. She haha just received Stadol 2mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? A. Variable decelerations B. Late decelerations C. Decreased variability D. Transient accelerations

C

An OB is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? A. Maternal BP B. Maternal pulse C. Fetal heart rate D. Fetal fibronectin level

C

When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place the FHR monitor? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

C

While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? A. The fetal position is transverse B. The fetal presentation is vertex C. The fetal lie is vertical D. The fetal attitude is flexed

C

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: A. 9 cm dilated, 70% effaced, and +2 station. B. 9 cm dilated, 80% effaced, and +3 station. C. 10 cm dilated, 90% effaced, and +4 station. D. 10 cm dilated, 100% effaced, and +5 station.

D