O5: L&D

An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care. She had no childbirth preparation. She is crying loudly and shouting, Please give me something for the pain. I can't take the pain. What is the priority nursing diagnosis? A. Pain related to uterine contractions B. Knowledge deficit related to the birth experience C. Ineffective coping related to inadequate preparation for labor D. Risk for injury related to lack of prenatal care

A

The initial nursing action immediately after an epidural block is initiated for a laboring woman would be to: A. Palpate the bladder for distention B. Measure the woman's blood pressure C. Assess sensation in the lower extremities D. Decrease intravenous fluid flow rate

B

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? A. Ambulation B. Rest between contractions C. Change positions frequently D. Consume oral food and fluids

B

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? A. Increased urinary output B. A fetal heart rate of 90 beats/minute C. 3 contractions occurring within a 10-minute period D. Adequate resting tone of the uterus palpated between contractions

B

When the nurse observes the patient bearing down with contractions and crying out, The baby is coming! the nurse should: A. Go and find the physician B. Stay with the woman and use the call bell to get help C. Send the woman s partner to locate a registered nurse D. Assist with deep breathing to slow the labor process

B

Which of the following is a sign of true labor? A. Intensity decreased with walking B. Intensity increased with walking C. No cervical change D. Irregular frequency

B

A narcotic antagonist used to reverse narcotic-induced respiratory depression is: A. Hydroxyzine (Vistaril) B. Phenobarbita C. Naloxone (Narcan) D. Nitrous oxide

C

The most important nursing activity during the fourth stage of labor is to: A. Monitor the frequency and intensity of contractions B. Provide comfort measures C. Assess for hemorrhage D. Promote bonding

C

The nurse recognizes the contraction duration and interval that could result in fetal compromise is: A. Duration shorter than 30 seconds, interval longer than 75 seconds B. Duration shorter than 90 seconds, interval longer than 120 seconds C. Duration longer than 90 seconds, interval shorter than 60 seconds D. Duration longer than 60 seconds, interval shorter than 90 seconds

C

The nurse, while caring for a woman in the first stage of labor, reminds the patient that contractions during this stage of labor: A. Get the baby positioned for delivery B. Push the baby into the vagina C. Dilate and efface the cervix D. Get the mother prepared for true labor

C

Which of the following is not a characteristic of the second stage of labor? A. Urge to push B. Increase in bloody show C. Weakening contractions D. Presenting part is visible

C

Which of the following nursing actions would be appropriate in preventing complications related to infection after the rupture of membranes? A. Frequent vaginal exams B. Provide ice chips C. Assess fetal heart rate for tachycardia D. Document the amount of vaginal bleeding every hou

C

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? Select all that apply. A. The contractions are regular. B. The membranes have ruptured. C. The cervix is dilated completely. D. The client begins to expel clear vaginal fluid. E. The spontaneous urge to push is initiated from perineal pressure.

C, E

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by: A. Contractions that are relieved by walking B. Discomfort in the abdomen and groin C. A decrease in vaginal discharge D. Regular contractions becoming more frequent and intense

D

During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may: A. Interfere with cervical dilation B. Obstruct progress of the infant through the birth canal C. Obstruct the passage of the placenta D. Predispose the mother to uterine hemorrhage

D

Several hours into labor, a woman complains of blurred vision, numbness, and tingling of her hands and mouth. The nurse recognizes these as symptoms of: A. Hypertension B. Anxiety C. Anoxia D. Hyperventilation

D

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? A. Assessing the mother's reflexes B. Taking the mother's temperature C. Taking the mother's apical pulse D. Monitoring the mother's blood pressure

D

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? A. Hematoma B. Uterine atony C. Placenta previa D. Placental separation

D

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 if she makes which statement? A. "I won't be in labor until my baby drops." B. "My contractions will be felt in my abdominal area." C. "My contractions will not be as painful if I walk around." D. "My contractions will increase in duration and intensity."

D

Which of the following is true of measuring the frequency of contractions? A. It is the beginning of uterine contraction to the end B. Most often it is measured in seconds C. It is the end of one uterine contraction to the beginning of the next D. Most often it is measured in minutes

D