Labor/Delivery

The nurse is caring for a client who is in active labor at 39 weeks gestation and receiving a continuous intravenous (IV) infusion of oxytocin. The nurse notes frequent and persistent late decelerations on the fetal monitor. What actions should the nurse take? Select all that apply. 1. Administer oxygen via a nonrebreather face mask. 2. Change the maternal position to the lateral side. 3. Discontinue oxytocin infusion. 4. Notify the health care provider. 5. Perform a nitrazine test.

1. Administer oxygen via a nonrebreather face mask. 2. Change the maternal position to the lateral side. 3. Discontinue oxytocin infusion. 4. Notify the health care provider.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counter pressure to the client's sacrum during contractions. 2. Encouraging the client to remain in bed during early labor. 3. Positioning the client on the left side with pillows for support. 4. Requesting that the nurse anesthetist administer epidural anesthesia.

1. Applying counter pressure to the client's sacrum during contractions.

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly. 2. Ensure availability of calcium gluconate. 3. Ensure bright lighting to prevent falls. 4. Have supplemental oxygen at bedside. 5. Limit visitors to minimize stimulation.

1. Assess deep tendon reflexes hourly. 2. Ensure availability of calcium gluconate. 4. Have supplemental oxygen at bedside. 5. Limit visitors to minimize stimulation.

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply. 1. Assessing the fetal heart rate before and after the procedure. 2. Checking the client's temperature every 2 hours. 3. Informing the client she will feel a sharp pain during the procedure. 4. Keeping the client in a supine position after the procedure. 5. Noting the characteristics of the amniotic fluid.

1. Assessing the fetal heart rate before and after the procedure. 2. Checking the client's temperature every 2 hours. 5. Noting the characteristics of the amniotic fluid.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation fo contractions an maternal tachycardia. 2. Fetal tachycardia with moderate variability. 3. Increased anxiety and discomfort with contractions. 4. Painful, strong contractions every 3 to 4 minutes.

1. Cessation fo contractions an maternal tachycardia.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds. 2. Contraction frequency of every 3 minutes. 3. Contraction intensity of 45 mm Hg. 4. Uterine resisting tone of 10 mm Hg.

1. Contaction duration of 95 seconds.

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply. 1. Contractions that increase in frequency. 2. Contractions that lessen after resting. 3. Increased blood-tinged, mucoid vaginal discharge. 4. Pain in lower back that moves to lower abdomen. 5. Progressive cervical effacement and dilation.

1. Contractions that increase in frequency. 4. Pain in lower back that moves to lower abdomen. 5. Progressive cervical effacement and dilation.

A pregnant client has labor induced with oxytocin infusion. The nurse assesses that the client has had 6 contractions in the past 10 minutes with a resting tone of 25 mm Hg. Fetal heart rate tracing shows a change in the baseline rate from 145/min to 170/min and minimal variability. What is the nurse's order of priority action? All options must be used. - Adminiser 10 L/min oxygen by face mask. - Document the findings. - Notify the health care provider. - Reposition the client in side-lying position. - Stop oxytocin infusion.

1. Stop oxytocin infusion. 2. Reposition the client in side-lying position. 3. Administer 10 L/min oxygen by face mask. 4. Notify the health care provider. 5. Document the findings.

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which nursing actions are appropriate during oxytocin infusion? Select all that apply. 1. Administering IV oxytocin via the distal port. 2. Assessing uterine contraction pattern. 3. Auscultating fetal heart rate intermittently. 4. Monitoring intake and output. 5. Placing the IV oxytocin on an electronic infusion pump.

2. Assessing uterine contraction pattern. 4. Monitoring intake and output. 5. Placing the IV oxytocin on an electronic infusion pump.

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene? 1. Documenting a positive nitrazione test result when the strip turns blue. 2. Donning non sterile and using soluble gel for vaginal examination. 3. Palpating the client's abdomen before applying external fetal monitors. 4. Providing the client with a variety of clear liquids to drink.

2. Donning non sterile and using soluble gel for vaginal examination.

A nurse is preparing to administer oxytocin to induce labor in a client. The nurse recognizes that the oxytocin infusion can lead to which of the following? 1. Decreased postpartum hemorrhage. 2. Delayed milk production. 3. Fetal distress and cesarean birth. 4. High risk of placenta previa.

3. Fetal distress and cesarean birth.

Four clients in labor are requesting pain medication from the nurse. Which client can safely receive an opioid agonist-antagonist analgesic intravenous (IV) push at this time? 1. Gravida 1, 2 cm dilated, 50% effaced, contractions 7 to 10 minutes apart, crying. 2. Gravida 1, 6 cm dilated, 75% effaced, contractions 2 to 4 min apart, has history of heroin use. 3. Gravida 2, 5 cm dilated, 100% effaced, contractions 3 to 4 minutes apart, moaning and shaking. 4. Gravida 4, 10 cm dilata, 100% effaced, contractions 2 to 3 minutes apart, wants to push.

3. Gravida 2, 5 cm dilated, 100% effaced, contractions 3 to 4 minutes apart, moaning and shaking.

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider? 1. Clean the perineal area. 2. Gently pull on the cord. 3. Keep the infant warm. 4. Massage the fundus.

3. Keep the infant warm.

A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is the priority and requires a nursing response? 1. Apgar score of 7 at 1 minute. 2. Apical heart rate of 160/min. 3. Circumoral duskiness. 4. Jitteriness.

4. Jitteriness.

A woman delivers her baby immediately on arrival at the emergency department and 5 minutes later delivers the placenta. The nurse's assessment is that the woman's uterus is boggy and midline. What action should the nurse take first? 1. Administer uterotonic oxytocin. 2. Ask the woman if afterpains are present. 3. Have the woman void. 4. Massage the fundus.

4. Massage the fundus.

A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure. 2. Perform Leopold maneuvers. 3. Perform the McRoberts maneuver. 4. Position the client on hands and knees.

4. Position the client on hands and knees.

A client at 38 weeks gestation is in labor and receiving an oxytocin infusion. The continuous fetal heart rate (FHR) monitor displays the strip shown in the exhibit. Which action by the nurse is most appropriate? Click on the exhibit button for additional information. 1. Discontinue oxytocin infusion. 2. Place client in the side-lying position. 3. Provide oxygen 10 L/min via face mask. 4. Review medication administration record.

4. Review medication administration record.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervidal lacerations. 2. Inversion of the uterus. 3. Uterine atony. 4. Vaginal hematoma.

4. Vaginal hematoma

What is an appropriate nursing intervention after the birth of a newborn with anencephaly? 1. Instruct the parents that visitors should be restricted. 2. Provide information to the parents about genetic counseling. 3. Refer the parents to a perinatal loss support group. 4. Wrap the newborn in warm blankets for the parents to hold.

4. Wrap the newborn in warm blankets for the parents to hold.

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply. 1. Ask the parents if they would like to help bathe the infant. 2. Discourage the parents from naming the infant. 3. Discuss the importance of organ donation with the parent. 4. Encourage the parents and family members to hold the infant. 5. Offer to obtain handprints, footprints, and photographs of the infant.

1. Ask the parents if they would like to help bathe the infant. 4. Encourage the parents and family members to hold the infant. 5. Offer to obtain handprints, footprints, and photographs of the infant.

A nurse is evaluating the external fetal monitoring strip of a laboring primigravida at 36 weeks gestation. Which nursing interventions should the nurse implement? Click on the exhibit button for additional information. Select all that apply. 1. Administer supplemental oxygen by mask. 2. Increase the intravenous (IV) fluid rate. 3. Prepare the client for an amnioinfusion. 4. Reposition the client to the supine position. 5. Stop the client's oxytocin infusion.

1. Administer supplemental oxygen by mask. 2. Increase the intravenous (IV) fluid rate. 5. Stop the client's oxytocin infusion.

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client? 1. Administration fo prophylactic antibiotics. 2. Assessment of uterine contraction frequency. 3. Collection of a clean-catch urine specimen. 4. Vaginal examination to assess cervical dilation.

1. Administration fo prophylactic antibiotics.

A pregnant client arrives in the emergency department by ambulance, reporting that her "water broke" at home. She is screaming and bearing down with every contraction. What questions are essential to ask in preparation for the birth and possible neonatal resuscitation? Select all that apply. 1. How many babies are you expecting? 2. What color was the fluid when your water broke? 3. What drugs did you take in the last 4 hours? 4. When is your due date? 5. Who is your health care provider?

1. How many babies are you expecting? 2. What color was the fluid when your water broke? 3. What drugs did you take in the last 4 hours? 4. When is your due date?

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place.

1.2 mL

A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first? Click on the exhibit button for additional information. 1. Administer IV fluid bolus. 2. Assess for umbilical cord prolapse. 3. Notify the health care provider. 4. Reposition client to the alternate side.

2. Assess for umbilical cord prolapse.

A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action? Click on the exhibit button for additional information. 1. Apply oxygen 10 L/min face mask. 2. Continue to monitor the client. 3. Discontinue oxytocin infusion. 4. Notify the health care provider.

2. Continue to monitor the client.

The nurse in the operating room is preparing for an emergency dilation and curettage post vaginal delivery for placenta accreta. What information is most important when reviewing this client's chart? 1. Client has been NPO and has no metal on the body. 2. Client has stable vital signs and has signed consent. 3. Client has type and crossmatch on file and at least 2 patent large-bore sites. 4. Client is on oxygen and has a patent IV site.

3. Client has type and crossmatch on file and at least 2 patent large-bore sites.

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes. 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg. 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation. 4. Client with spontaneous rupture of membranes with greenish amniotic fluid.

4. Client with spontaneous rupture of membranes with greenish amniotic fluid.

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? 1. Administer prescribed IV meperidine for pain relief. 2. Encourage client to bear down with spontaneous urges to push. 3. Place client in the lithotomy position in preparation for birth. 4. Provide encouragement and coaching in breathing techniques.

4. Provide encouragement and coaching in breathing techniques.