NUR2234 Exam 3
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees
1.
The nurse in the labor room is caring for a client in active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask 2. Place the mother in a supine position 3. Increase the rate of the oxytocin intravenous infusion 4. Document the findings and continue to monitor the fetal patterns
1.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the FHR between contractions is 100 bpm. Which nursing action is most appropriate? 1. Notify the health care provider 2. Continue monitoring the fetal heart rate 3. Encourage the client to continue pushing with each contraction 4. Instruct the client's coach to continue to encourage breathing techniques
1.
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids
2.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider? 1. Hgb 11 g/dL 2. FHR of 180 bpm 3. Maternal pulse rate of 85 bpm 4. WBC 12,000
2.
Android
This type of pelvic is characterized by its funnel shape. Descent of the fetal head into the pelvis is slow, and failure of the fetus to rotate is common. Prognosis for labor is poor, subsequently leading to cesarean birth.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations
4.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor is she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."
4.
___________ station is designated when the presenting part is at the level of the maternal ischial spines.
Zero
External rotation
Allows the shoulders to rotate internally to fit the maternal pelvis
__________ describes the irregular variations or absence of FHR due to erroneous causes on the fetal monitor record.
Artifact
Amniotomy
Artificial rupture of the membranes (AROM), using a plastic amnihook or a surgical clamp, done by the health care provider
Descent
Downward movement of the fetal head until it is within the pelvic inlet. A maneuver that occurs throughout the laboring process
The thinning out process of the cervix during labor is termed _________
Effacement
Station
For testing purposes : Remember the station is measured in cm and uses the ischial spine as a reference point to assist in answering questions. Stations range from -5 to +5 cm above or below the ischial spine. -5 = fetal presenting 5 cm above the ischial spine +5 = fetal presenting 5 cm below the ischial spine
Types of Breech positions
Frank breech - butt first (coming out of the vagina first), legs straight up to head, arms crossed across the chest and head tucked to chin Complete breech - butt first (coming out of the vagina first), legs crossed indian style, arms crossed across chest, head tucked to chin Single footling breech - one leg straight out (coming out of the vagina first) and the other leg bent up to chest with arms crossed across chest and head tucked to chin Double footling breech - both legs straight out (coming out of the vagina first), arms crossed across chest, head is straight forward
Phases of labor
Latent - Active - Transition - Pelvic - Perineal - Placental separation - Placental expulsion
_________ occurs when the fetal presenting part begins to descend into the maternal pelvis
Lightening
__________ comfort measures are usually simple, safe, effective, and inexpensive to use.
Nonpharmacologic
Flexion
Occurs as the vertex meets resistance from the cervix, walls of the pelvis, or the pelvic floor
The elongated shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as __________
molding
Engagement
occurs when the greatest transverse diameter of the head in vertex passes through the pelvic inlet
Baseline variability represents the interplay between the ____________ and sympathetic nervous system.
parasympathetic
The birth __________ is the route through which the fetus must travel to be birthed vaginally.
passageway
Third-degree laceration
through the anal sphincter muscle
Fourth-degree laceration
through the anterior rectal wall
Second-degree laceration
through the muscles of the perineal body
First-degree laceration
through the skin
The ______________ is placed over the uterine fundus in the area of greatest contractility to electronically monitor uterine contractions.
tocotransducer
The primary power of labor is/are __________ contractions, which are involuntary.
uterine
The nurse reviews the prenatal record to identify risk factors that may contribute to a decrease in _______ circulation during pregnancy and/or labor.
uteroplacental
A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated FHR changes. Which intervention should the nurse perform to manage the changes? a. assist client to a supine position b. provide supplemental oxygen c. discontinue IV fluids d. turn client to her right side
b.
A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's VS? a. every 15 min b. every 30 min c. every 45 min d. every 1 hour
b.
The __________ spines serves as landmarks for estimating the descent of the fetal presenting part and have been designated as zero station.
ischial
A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? a. local infiltration b. epidural block c. regional anesthesia d. general anesthesia
d.
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the EFM, what is the next nursing action? 1. Identify the types of acceleration 2. Assess the baseline FHR 3. Determine the intensity of the contractions 4. Determine the frequency of the contractions
2.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120-122 bpm for the past hour. What is the priority nursing action? 1. Notify the health care provider 2. Discontinue the infusion of oxytocin 3. Place oxygen on at 8-10 L/min via face mask 4. Contact the client's primary support person if not currently present
2.
Which assessment following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure
3.
A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? SATA 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
3. 5.
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? SATA 1. The contractions are regular 2. The membranes have ruptured 3. The cervix is dilated completely 4. The client begins to expel clear vaginal fluid 5. The spontaneous urge to push is initiated from perineal pressure
3. 5.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the EFM tracing. Which action is most appropriate? 1. Notify the health care provider of the findings 2. Reposition the mother and check the monitor for changes in the fetal tracing 3. Take the mother's VS and tell the mother that bed rest is required to conserve oxygen 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well being
4.
Extension
The head emerges through extension under the symphysis pubis, along with the shoulders
Anthropoid
Vaginal birth is more favorable with this pelvic shape (deep pelvis, wider front-to-back than side-to-side) compared to the android or platypelloid shape.
A nurse is required to obtain the fetal heart rate for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly? a. lower quadrant of the maternal abdomen b. at the level of the maternal umbilicus c. above the level of the maternal umbilicus d. just below the maternal umbilicus
a
The assessment of a pregnant client, who is toward the end of her third trimester, reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client? SATA a. Reduction in cervical resistance b. myometrial contractions c. boggy appearance of the uterus d. softening and thinning of the cervix e. hypotonic character of the bladder
a, b, d
A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? a. determine if the client is in true or false labor b. ask if this is the client's first pregnancy c. notify the health care provider d. assess to see if the client has any drug allergies
a.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? a. these contractions help in softening and ripening the cervix b. these contractions increase the release of prostaglandins c. these contractions increase oxytocin sensitivity d. these contractions make maternal breathing easier
a.
A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor? a. increased sedation b. newborn respiratory depression c. nervous system depression d. decrease alertness
a.
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? a. respiratory rate b. temperature c. pulse d. uterine contractions
a.
A pregnant client has opted for hydrotherapy for pain management during labor. Which should the nurse consider when assisting the client during the birthing process? a. initiate the technique only when the client is in active labor b. do not allow the client to stay in the bath for long c. ensure that the water temp exceeds body temp d. allow the client into the water only if her membranes have ruptured
a.
The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? a. external electronic fetal monitoring b. fetal blood pH c. fetal oxygen saturation d. fetal position
a.
A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? SATA a. provide the client clear information on procedures involved b. encourage the client to have a sense of mastery and self-control c. encourage the client to have a positive reaction to pregnancy d. instruct the client to spend some time alone each day e. instruct the client to begin changing the home environment
a. b. c.
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client, as the client progresses through birth? SATA. a. increase in HR b. increase in BP c. increase in RR d. slight decrease in body temp e. increase in gastric emptying and pH
a. b. c.
The nurse explain Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? SATA a. determining the presentation of the fetus b. determining the position of the fetus c. determining the lie of the fetus d. determining the weight of the fetus e. determining the size of the fetus
a. b. c.
A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? SATA a. Spinal abnormality b. hypovolemia c. varicose veins d. coagulation defects e. skin rashes or bruises
a. b. d.
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? SATA a. uterine resting tone b. frequency of contractions c. change in temperature d. change in BP e. intensity of contractions
a. b. e.
A nurse caring for a pregnant client in labor observes that the FHR is below 110 bpm. Which interventions should the nurse perform? SATA a. Turn the client on her left side b. reduce IV fluid rate c. Administer oxygen by mask d. Assess client for underlying causes e. Ignore questions from client
a. c. d.
A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which information should the nurse obtain from the client? SATA a. estimated due date b. history of drug abuse c. characteristics of contractions d. appearance of vaginal blood e. history of drug allergy
a. c. d.
A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client? SATA a. hand holding b. chewing gum c. massaging d. acupressure e. prescribed pain killers
a. c. d.
A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands which to be causes of the extreme pain in the client? SATA a. lower uterine segment distention b. fetus moving along the birth canal c. stretching and tearing of structures d. spontaneous placental expulsion e. dilation of the cervix
a. c. e.
Fetal ____________ are transitory increases in the FHR above the baseline that are associated with sympathetic nervous stimulation.
accelerations
Order of nursing interventions during various stages of labor and birth
ascertain whether the woman is in true or false labor check the fundus to ensure that it is firm (size and consistency of a grapefruit), located in the midline and below the umbilicus Position the woman and cleanse the vulva and perineal areas Check for crowning, low grunting sounds from the woman, and increase in blood-tinged show Check for lengthening of the umbilical cord protruding from the vagina
A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next? a. Notify the health care provider b. Continue to monitor the client c. assess the client's BP d. prepare the client for birth
b
A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next? a. continue to monitor the client b. continue to massage the client's fundus c. administer oxygen to the client d. assess the client's vaginal bleeding
b.
A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? a. inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds b. inhale slowly through the nose and exhale through pursed lips c. punctuated breathing by a forceful exhalation through pursed lips every few breaths d. hold breath for 5 seconds after every 3 breaths
b.
A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess? a. uterine abnormalities b. fetal anomalies c. congenital anomalies d. prematurity
b.
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? a. monitor VS b. assess amount of cervical dilation c. obtain urine specimen for urinalysis d. monitor hydration status
b.
A 20-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? a. prepare the client for birth b. assess the client's cervical status c. notify health care provider d. perform leopold's maneuver
c.
A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? a. to reduce boggy nature of the uterus b. to remove pieces left attaches to uterine wall c. to constrict the uterine blood vessels d. to lessen the chances of conducting an episiotomy
c.
A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? a. long axis of fetus is at 60 degrees to that of client b. long axis of fetus is parallel to that of client c. long axis of fetus is perpendicular to that of client d. long axis of fetus is 45 degrees to that of client
c.
A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who ahs already delivered once and is pregnant a second time. What explanation should the nurse offer the client? a. Braxton Hicks contractions are not strong enough during the first pregnancy b. contractions are stronger during the first pregnancy than the second c. the cervix takes around 12 to 16 hours to dilate during first pregnancy d. spontaneous rupture of membranes occurs during first pregnancy
c.
The nurse caring for a client in preterm labor observes abnormal fetal heart rate patterns. Which nursing interventions should the nurse perform next? a. application of vibroacoustic stimulation b. tactile stimulation c. administration of oxygen by mask d. fetal scalp stimulation
c.
The nurse is monitoring a pregnant client admitting to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the FHR with the Doppler at least how often? a. every 15-30 min b. every 30 min c. every hour d. continuously
c.
A nurse is caring for a client in labor who is delivering. For which fetal response should the nurse monitor? a. decrease in arterial carbon dioxide pressure b. increase in fetal breathing movements c. increase in fetal oxygen pressure d. decrease in circulation and perfusion to the fetus
d.
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? a. diffuse abdominal cramping b. rupturing of fetal membranes c. start of regular contractions d. dilation of cervix diameter to 10 cm
d.
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? a. effacement and dilation of the cervix b. shortening of the upper uterine segment c. reduction in length of the cervical canal d. restoration of blood flow to uterus and placenta
d.
A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor? a. it helps the woman in labor to save energy b. it facilitates vaginal examinations c. it facilitates external belt adjustment d. it helps to rotate the fetus in a posterior position
d.
Oxytocin aids in stimulating prostaglandin synthesis through receptors in the _____________
decidua
If the nitrazine test is inconclusive, an additional test, called the ________ test, can be used to confirm rupture of membranes.
fern
Platypelloid
flat pelvis; this is the least common type of pelvic structure. The pelvic cavity is shallow but widens at the pelvic outlet, making it difficult for the fetus to descend through the midpelvis. It is not favorable for a vaginal birth unless the fetal head can pass through the inlet. Women with this type of pelvis usually require cesarean birth.
Vaginal birth is most favorable with __________ type of pelvis because the inlet is round and the outlet is roomy.
gynecoid
If the woman is a diabetic, it is critical to alert the newborn nursery of potential __________ in the newborn.
hypoglycemia
A sudden increase in energy on the part of the expectant woman 24-48 hrs before the onset of labor is sometimes referred to as ____________
nesting
The _______________ suture is located between the parietal bones and divides the skull into the right and left halves.
sagittal
An increase in prostaglandins leads to myometrial ____________ and to a reduction in cervical resistance.
sensitization
Gynecoid
this is considered the true female pelvis, occurring in about 50% of all women. Vaginal birth is most favorable with this type of pelvis because the inlet is round and the outlet is roomy.
