Lippincott L&D

After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? "I should try to push with each contraction." "My membranes are likely to have a foul odor." "My contractions are going to be less painful." "I'm going to have a higher blood pressure."

"I should try to push with each contraction."

A pregnant client's partner coaches her with breathing and relaxation techniques as they were taught in birth preparation classes. When the client reaches 8-cm dilation, she screams out, "I can't do this anymore!" Which suggestion would be most helpful for the client's partner? "Maintain direct eye contact and breathe with her." "Ask your partner if she wants anesthesia." "Let me take over the coaching for a while." "Tell your partner that it will be over soon."

"Maintain direct eye contact and breathe with her."

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes? Position the client on her left side. Assess the client's blood pressure. Prepare the client for a cesarean birth. Check the fetal heart rate.

Check the fetal heart rate.

The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do? Continue to monitor the client and fetus. Turn the client to her left side. Ask the client to push in the squatting position. Administer oxygen by mask at 8 L.

Continue to monitor the client and fetus.

A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first? Initiate fetal and contraction monitoring. Administer betamethasone. Obtain the urine specimen. Start the intravenous infusion.

Initiate fetal and contraction monitoring

A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. Request pain medication on a regular basis. Lightly massage the abdomen. Walk in the hospital room. Use slow chest breathing. Sip ice water.

Lightly massage the abdomen. Walk in the hospital room. Use slow chest breathing.

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction? hypotension. headache. tremors. diaphoresis.

hypotension

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? episodes of nausea and vomiting an increased sense of rectal pressure a decrease in intensity of contractions an increase in fetal heart rate variability

an increased sense of rectal pressure

A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor? painful contractions every 3 to 5 minutes fetal descent into the pelvic inlet cervical dilation and effacement leaking amniotic fluid clear in color

cervical dilation and effacement

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client? left lateral right lateral supine prone

left lateral

Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position? transverse breech posterior anterior

posterior

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition? fetal head engagement a need for an analgesic medication prolapsed cord increased intensity of contractions

prolapsed cord

A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time? preparing for immediate delivery providing comfort measures checking for ruptured membranes placing the client in bed to begin fetal monitoring

preparing for immediate delivery

Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Who will be with you during labor?" "Do you have any chronic illnesses?" "What is your expected due date?" "Do you have any allergies?"

"What is your expected due date?"

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? The uterus cannot be palpated. The cord lengthens outside the vagina. There is decreased vaginal bleeding. The uterus changes to discoid shape.

The cord lengthens outside the vagina.

The end of the third stage of labor is marked by what event? delivery of the placenta transfer of the client to the postpartum bed the birth of the neonate complete dilation

delivery of the placenta

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia? abnormally long uterine contractions excessively frequent contractions, with rapid fetal movement excessive fetal activity and fetal tachycardia abnormally strong uterine contractions

excessive fetal activity and fetal tachycardia

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness

fetal heart rate

A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply. interpretation of the fetal monitor strip support persons with the client analgesia or anesthesia being used prior birth history amount of vaginal bleeding or discharge

interpretation of the fetal monitor strip support persons with the client analgesia or anesthesia being used prior birth history amount of vaginal bleeding or discharge

A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? pain ineffective coping hyperventilation urinary retention

pain

The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? passage of meconium by the fetus Rh incompatibility between mother and fetus maternal sexually transmitted disease maternal intrauterine infection

passage of meconium by the fetus

he cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time? walking around in the hallway sitting in a comfortable chair for a period of time lying in the left lateral recumbent position resting in the right lateral recumbent position

walking around in the hallway

A primary care provider has prescribed nalbuphine hydrochloride 10 mg intravenously for a client in active labor. The pharmacy supplies a vial labeled as 50 mg in a 5-mL vial. How many milliliters should the nurse administer? Record your answer using a whole number.

1

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? duration, frequency, and intensity dilation, duration, and frequency dilation, effacement, position frequency, duration, maternal position

duration, frequency, and intensity

A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? The color of the ruptured fluid The frequency of contractions The presence of fetal movement after the membranes ruptured The time of membrane rupture

The time of membrane rupture

When assessing the fetal heart rate tracing, a nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve: the status of a trapped cord. fetal hypoxia. maternal comfort. the contraction pattern.

fetal hypoxia.

The nurse is caring for a client in active labor. As the nurse is evaluating the fetal heart rate pattern below, identify the area of concern that suggests umbilical cord compression.

first variable deceleration

A nurse recognizes that labor is divided into how many stages? two five three four

four

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? numbness of the legs loss of control feelings of relief excitement

loss of control

What assessment data of a laboring woman would require further intervention by the nurse? maternal heart rate 125 beats/minute moderate contractions 3 minutes apart temperature of 99.1° F (37.27° C) fetal heart rate (FHR) 150 beats/minute

maternal heart rate 125 beats/minute

What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia? offering encouragement and support applying extra blankets for warmth giving frequent sips of water providing frequent perineal cleansing

offering encouragement and support

Which statement describes the term fetal position? relationship of the fetus's presenting part to the mother's pelvis fetal posture relationship of the fetal long axis to the mother's long axis fetal head or breech at cervical os

relationship of the fetus's presenting part to the mother's pelvis

When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if the fetal heart rate remains at greater than 160 beats/minute for 10 minutes. the fetal heart rate remains at greater than 160 beats/minute for more than 20 minutes. the fetal heart rate remains at greater than 160 beats/minute for 5 minutes. the fetal heart rate is at least 170 beats/minute at any time.

the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.

Which fetal presentation is most favorable for birth? vertex presentation posterior position of the fetal head transverse lie frank breech presentation

vertex presentation

The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client makes which statement? "If I have a cesarean, I can have an epidural." "I can have an epidural as soon as I start contracting." "Nalbuphine and promethazine will give relief from pain and nausea during early labor." "If I have an emergency cesarean, I may be put to sleep for the birth."

"I can have an epidural as soon as I start contracting."

Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients? The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. The nurse should assign priority to the first client. Her leaking amniotic fluid indicates that she'll soon go into labor. Triage observation is appropriate for both clients at this time. It doesn't matter which client receives priority; they're at the same stage of labor.

The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? Flex the thighs onto the abdomen before bearing down. Exert downward pressure as if having a bowel movement. Be in a semi-Fowler's position or a position of comfort Hold the breath throughout the length of the contraction.

Hold the breath throughout the length of the contraction.

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? Note the color, amount, and odor of the amniotic fluid. Prepare the client for imminent birth. Auscultate the client's blood pressure. Perform a vaginal examination to determine dilation.

Note the color, amount, and odor of the amniotic fluid.

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? sleeping after administration of IV nalbuphine contractions 3 minutes apart and lasting 40 seconds evidence of spontaneous rupture of the membranes an episode of nausea after administration of an epidural anesthetic

evidence of spontaneous rupture of the membranes

In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia late decelerations fetal heart rate accelerations variable decelerations

fetal heart rate accelerations

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? head placenta umbilical cord chest

umbilical cord

multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? Prepare for birth. Have naloxone hydrochloride available in the birthing room. Document the client's relief due to pain medication. Complete a vaginal examination.

Complete a vaginal examination.

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse? Notify the provider, explain findings to the client, and begin pushing. Perform sterile vaginal examination, increase IV fluids, and apply oxygen. Reposition the client, apply oxygen, and increase IV fluids. Prepare for birth, reposition the patient, and begin pushing.

Reposition the client, apply oxygen, and increase IV fluids.

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? latent phase descent phase transitional phase active phase

transitional phase

A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor and possible vaginal birth. After several hours of active labor, the primary care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which statement? "I'll be able to get some sleep until after the birth." "The contractions don't seem as painful as before." "I don't feel that burning sensation in my stomach anymore." "I don't feel the nausea like I did the last time.

"The contractions don't seem as painful as before."

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions? "Walking around helps to decrease true contractions." "The duration and frequency of true labor contractions remain the same." "True labor contractions may disappear with rest or sleep." "True labor contractions are felt first in the lower back, then the abdomen."

"True labor contractions are felt first in the lower back, then the abdomen."

A nurse needs to obtain a good monitor tracing on a client in labor. The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first? Reposition the client to her left side. Immediately take the client's blood pressure and summon the health care provider (HCP). Increase the IV fluids to correct the client's dehydration. Start oxygen at 6 L via nasal cannula.

Reposition the client to her left side.

The nurse is managing care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client? anesthesia/pain level assessment every 30 minutes oxygen saturation monitoring every half hour supine positioning on back, if it is comfortable vaginal bleeding, rupture of membrane assessment every shift

anesthesia/pain level assessment every 30 minutes

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? acme of one contraction to the beginning of the next contraction beginning of one contraction to the end of the next contraction end of one contraction to the end of the next contraction beginning of one contraction to the beginning of the next contraction

beginning of one contraction to the beginning of the next contraction

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? accelerations early decelerations late decelerations prolonged decelerations

early decelerations

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe? intramuscular cefaclor intravenous penicillin intravenous gentamicin sulfate intramuscular betamethasone

intravenous penicillin

Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client feels a strong need to have a bowel movement. What is the client most likely experiencing? spontaneous rupture of the membranes the second stage of labor fear and anxiety related to the labor outcome a precipitous labor pattern

the second stage of labor

A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client? Prepare for immediate administration of magnesium sulfate. Assess maternal contraction and fetal heart rate pattern. Reassure the client that this baby will be healthy. Review history of prior fetal demises with client.

Assess maternal contraction and fetal heart rate pattern.

A nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan? Acute pain related to labor contractions Anxiety related to the facility environment Compromised family coping related to hospitalization Fear related to a potentially difficult childbirth

Fear related to a potentially difficult childbirth

A nurse is evaluating an external fetal monitoring strip. Identify the area on this strip that causes the nurse to be concerned about uteroplacental insufficiency.

late deceleration

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? transitional phase expulsive phase active phase latent phase

latent phase

External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first? Change the client's position. Notify the anesthesiologist. Prepare the client for a cesarean birth. Administer oxygen at 2 L by mask.

Change the client's position.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Administer oxytocin intravenously. Cover the cord with sterile towels. Place the client in a Trendelenburg position. Ask the client to begin pushing.

Place the client in a Trendelenburg position.