Intrapartum
A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? A. Assist mother with childbirth breathing B. Encourage mother to have an epidural C. Provide direct sacral pressure D. Move the woman to a hydrotherapy tub
C When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.
On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior (ROA), 7 cm 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 Descent is progressing well. The presenting part is 3 centimeters below the ischial spines.
The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? A. Left occipital anterior (LOA) B. Left sacral posterior (LSP) C. Right mentum anterior (RMA) D. Right sacral posterior (RSP)
A The nurse's findings upon performing Leopold maneuvers indicate that the fetus is in the left occiput anterior (LOA) position - that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis.
A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? A. Encourage the woman to have an epidural B. Encourage the woman to accept intravenous analgesia C. Encourage the woman to change her position D. Encourage the woman to perform the next level breathing
D This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.
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 blood pressure C. The gestational age of the fetus D. The placement of the fetal heart electrode in relation to the fetal position
A The relationship between the decelerations and the contractions will determine the type of deceleration pattern.
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 beats per minute (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 intravenous
A The tracing is showing a normal fetal heart tracing. No intervention is needed.
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? A. Inform the mother that the rate is normal B. Reassess in 5 minutes to verify 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 This is the correct response. A fetal heart rate of 152 is normal.
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 nurse to delegate to the doula? (Select all that apply) A. Give the woman a back rub B. Assist the woman with her breathing C. Assess the fetal heart rate D. Check the woman's blood pressure E. Regulate the woman's intravenous infusion rate
A,B -An appropriate action by the doula is giving the woman a back massage. -An appropriate action by the doula is to assist the laboring woman with her breathing.
In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? A. Lying in the lithotomy position B. Performing effleurage C. Practicing Kegel exercises D. Pushing with each contraction
B Effleurage is a light massage that can soothe the mother during labor.
The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? A. Sacral promontory B. Ischial spines C. Cervix D. Symphysis pubis
B Station is assessed by palpating the ischial spines.
During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm 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 The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and buttocks at -1 station are 1 cm above the ischial spines.
A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm 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. Off the client the bedpan B. Evaluate the progress of labor C. Notify the physician D. Encourage the patient to push
B The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.
A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? A. Awaken the woman and remind her to push B. Cover the woman's perineum with a sheet C. Assess the woman's blood pressure and pulse D. Administer oxygen to the woman via face mask
B The woman's privacy should be maintained while she is resting.
A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? A. Assess the blood pressure B. Have the woman breathe into a bag C. Turn the woman onto her side D. Check the fetal heart rate
B This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.
A nurse has just performed a vaginal examination 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. Left upper quadrant (LUQ) B. Left lower quadrant (LLQ) C. Right upper quadrant (RUQ) D. Right lower quadrant (RLQ)
C Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ.
An obstetrician 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 blood pressure B. Maternal pulse C. Fetal heart rate D. Fetal fibronectin level
C It is essential to assess the fetal heart rate immediately after an amniotomy.
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 With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical.
The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? (Select all that apply) A. Hypnotic suggestion B. Rhythmic chanting C. Muscle relaxation D. Pelvic rocking E. Abdominal massage
C,D,E -Muscle relaxation is an integral part of Lamaze childbirth education. -Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. -Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth eduction.
A woman 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 valuable information regarding the client's labor status? A. Leopold maneuvers B. Fundal contractility C. Fetal heart assessment D. Vaginal examination
D A vaginal examination will provide the nurse with the best information about the status of labor.
The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? A. After every contraction B. For 10 minutes every half hour C. Only during the peak of contractions D. For 1 minute immediately after contractions
D Intermittent auscultation should be performed for 1 full minute after contractions end.
Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse perform during the next contraction? A. Encourage the woman to push B. Provide firm fundal pressure C. Move the client into a squat D. Monitor for signs of rectal pressure
D Monitoring for rectal pressure is appropriate at this time.
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 -Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. -The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. -The client's age should also be noted before the physical assessment is begun. -The client's gravidity and parity - how many times she has been pregnant and how many times she has given birth - should also be noted before a physical assessment is begun.
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 examinations B. Before administration of analgesics C. Periodically at the end of a contraction D. Every ten minutes E. Before ambulating
A,B,C,E -The nurse should assess the fetal heart after all vaginal examinations. -The nurse should assess the fetal heart before giving the mother any analgesics. -The fetal heart should be assessed periodically at the end of a contraction. -The nurse should assess the fetal heart before the woman ambulates.
A woman has just arrived at the labor and delivery suite. 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 -The nurse should assess the fetal heart before reporting the client's status to the healthcare provider. -The nurse should assess the contraction pattern before reporting the client's status. -The nurse should assess the woman's vital signs before reporting her status.
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 the membranes D. Uncontrollable urge to push E. Inability to breathe through contractions
A,B,D as the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. -A bulging perineum indicates progression to the second stage of labor. -The bloody show increases as a woman enters the second stage of labor. -With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push.
The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? A. Alternately pan and blow B. Take rhythmic, shallow breaths C. Push down with an open glottis D. Do slow chest breathing
C Open glottal pushing is used during stage 2 of labor.
The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? A. Mothers who are performing breathing exercises during labor refrain from yelling B. Breathing and relaxation exercises are less exhausting than crying and moaning C. Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle D. Childbirth education classes help to promote positive maternal-newborn bonding
C Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.
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 a fetoscope to hear the fetal heartbeat? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant
C The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.
A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? A. Avoiding the discussion of uncomfortable procedures like vaginal examinations and blood tests B. Focusing the discussion on baby care rather than on labor and delivery C. Utilizing visual aids like movies and posters during the classes D. Having the classes at a location other than high school to reduce their embarrassment
C Using visual aids can help to foster learning in teens as well as adults.
The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely is which of the following positions? A. Mentum anterior B. Sacrum posterior C. Occiput posterior D. Scapula anterior
C When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain.
A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? A. Alternately panting and blowing B. Rapid, deep breathing C. Grunting and pushing with contractions D. Slow chest breathing
D Most women find slow chest breathing effective during the latent phase.
A client in labor, G2 P1001, was admitted 1 hour 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 and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? A. The client had poor childbirth 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 The woman is showing expected signs of the active phase of labor.
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 The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.
