OB test 2 Success Intrapartum

"298. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

1. "I will begin abdominal exercises immediately." "Rationale: A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery."

"303. Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Fetal heart rate pattern "Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"295. A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 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"

3. Increased efficiency of contractions "Rationale: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, however."

30. 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? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. It is essential to assess the fetal heart rate immediately after an amniotomy. Amniotomy, as the word implies, is the artificial rupture of the amniotic sac. During the procedure, there is a risk that the umbilical cord may become compressed. Because there is no direct way to assess cord compression, the nurse must assess the fetal heart rate for any adverse changes.

16. Which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear- tension-pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3. Knowledge learned at childbirth education classes helps to break the fear- tension-pain cycle.

17. The 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? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

3. Open glottal pushing is used during stage 2 of labor. Because the laboring client is in stage 2, the woman will change from using breathing techniques during contractions to pushing during contrac- tions to birth the baby. Open glottal pushing is recommended because pushing against a closed glottis can decrease the mother's oxygen saturation.

29. A client is complaining of severe back labor. Which of the following nursing inter- ventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

3. Provide direct sacral pressure. Whenever a laboring woman complains of severe back labor, it is very likely that the baby is lying in the occiput posterior position. Every time the woman has a contraction, the head is pushed into the coccyx. When direct pressure is applied to the sacral area, the nurse is providing counteraction to the pressure being exerted by the fetal head.

"291. The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 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."

3. The cervix is dilated completely. "Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1."

23. 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 as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2. The woman's privacy should be main- tained while she is resting. Because the woman is in second stage, she is pushing with contrac- tions. If she is very tired, she is likely to fall asleep immediately following a con- traction. It is important for the nurse to maintain the woman's privacy by covering her perineum with a sheet between con- tractions. It would also be appropriate to awaken the woman at the beginning of the next contraction.

"292. The nurse in the labor room is caring for a client in the 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 (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns."

1. Administer oxygen via face mask. "Rationale: Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment."

13. On examination, it is noted that a full-term primipara in active labor is right occipi- toanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1. Descent is progressing well. The pre- senting part is 3 centimeters below the ischial spines. This question includes a number of concepts. Descent and station are discussed in answer options 1 and 2. The dilation of the cervix, which is related to the fact that the woman is a primigravida, is discussed in choice 3. And, one of the cardinal moves of labor— external rotation—is included in choice 4. The test taker must be prepared to answer questions that are complex and that include diverse information. In a 7 cm dilated primipara, with a baby at +3 station, vaginal delivery is not imminent, but the fetal head is well past engagement and descent is progressing well. External rotation has not yet occurred because the baby's head has not yet been birthed.

"304. 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" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Rest between contractions "Rationale: The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

7. The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Station is assessed by palpating the ischial spines. The test taker must be thoroughly familiar with the anatomy of the female reproductive system and the measurements taken during pregnancy and labor. Station is determined by creating an imaginary line between the ischial spines. The descent of the presenting part of the fetus is then compared with the level of that "line."

70. A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

2. Hypertension. During contractions, the blood from the placenta is forced into the peripheral vascular system and there is an increase in cardiac output. As a result, the woman's blood pressure rises: an average of 35 mm Hg systolic and 25 mm Hg diastolic. The blood pressure should never be assessed during a contraction because the reading will be a marked distortion of the woman's true blood pressure.

77. Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

2. Hypotension is a very common side effect of regional anesthesia.

90. It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though." Peristalsis slows dramatically during labor. Because of this, women rarely become hungry during labor, but they do need fluids and some nourishment. Clear fluids, including ice chips, water, tea, and bouillon, are often allowed. Ultimately, though, it is the health care practitioner's decision what and how much the client may consume.

2. 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? 1. Leopold's maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. Vaginal examination. only assessment that will determine whether or not a woman is in true labor is a vaginal examination. Only when there is cervical change—dilation and/or effacement—is it determined that a woman is in true labor.

"296. 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. Variable decelerations" "Rationale: Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction."

34. The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Her cervix has dilated from 2 to 4 cm. Once the cervix begins to dilate, a client is in true labor.

6. 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. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 5. The nurse should assess the fetal heart before the woman ambulates. Except for invasive procedures, assessment of the fetal heart pattern is the only way to evaluate the well-being of a fetus during labor. The fetal heart pattern should, therefore, be assessed whenever there is a potential for injury to the baby or to the umbilical cord. At each of the times noted in the scenario—vaginal exam, analgesic administration, contraction, and ambulation—either the cord could be compressed or the baby could be compromised.

4. A woman has just arrived at the labor and delivery suite. To report the client's status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

1, 2, and 4 are correct. 1. The nurse should assess the fetal heart before reporting the client's status to the health care provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 4. The nurse should assess the woman's vi- tal signs before reporting her status. The fetal heart, contrac- tion pattern, and maternal vitals all should be assessed to provide the health care practitioner with a picture of the health status of the mother and fetus. In some institutions, the nurse may also do a vaginal examination to assess for cervical change.

35. The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 min- utes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconium- stained fluid. The client needs to be assessed. The mucous plug protects the uterine cavity from bacterial invasion. It is expelled before or during the early phase of labor. In fact, it may be hours, days, or even a week after the mucous plug is expelled before true labor begins.

9. 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. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, and 4 are correct. 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. 1. A bulging perineum indicates progres- sion to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. It is important that the test taker clearly understands the differ- ence between the three phases of the first stage of labor and the three stages of labor. The three phases of the first stage of labor—latent, active, and transition— are related to changes in cervical dilation and maternal behaviors. The three stages of labor are defined by specific labor pro- gressions—cervical change to full dilation (stage 1), full dilation to birth of the baby (stage 2), birth of the baby to birth of the placenta (stage 3).

75. A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

1. Fetal position.

8. The labor and delivery nurse performs Leopold's 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? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

1. Left occipital anterior (LOA). The nurse's findings upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior posi- tion (LOA)—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.

67. A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

1. Lengthening of the umbilical cord. 3. Uterus rising in the abdomen and feeling globular. Once second stage is complete, the baby is no longer in utero. Dilation and effacement are complete before second stage begins.Rectal pressure is usually a sign of fetal descent. Once the second stage is com- plete, the baby is no longer in utero.

"299. 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 fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 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. Notify the health care provider (HCP). "Rationale: A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention."

"297. 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. Supine position with a wedge under the right hip "Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's position or prone position is not practical for this type of abdominal surgery."

72. A nurse concludes that a woman is in the latent phase of labor. Which of the follow- ing signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

1. Talking and laughing are characteristic behaviors of the latent phase. Back labor can be experienced during any phase of labor. Women in the latent phase often do perform effleurage, but it can also be performed during other phases of labor. A woman in the latent phase might go to the bathroom but defecating is not indica- tive of the first phase of labor.

69. A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2cm. 2. 4cm. 3. 8cm. 4. 10 cm.

1. The nurse would expect the woman to be 2 cm dilated. At 4 cm, the woman is entering the active phase of labor. At 8 cm, the woman is in the transition phase of labor. At 10 cm, the woman is in the second stage of labor.

43. A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions.

1. The obstetric conjugate is the shortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head.

28. 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? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

1. The relationship between the decelera- tions and the contractions will deter- mine the type of deceleration pattern. Decelerations are defined by their relationship to the contraction pattern. It is essential that the nurse deter- mine which of the three types of decelera- tions is present. Early decelerations mirror contractions, late decelerations develop at the peak of contractions and return to baseline well after contractions are over, and variable decelerations can occur at anytime and are unrelated to contractions.

27. 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? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1. The tracing is showing a normal fetal heart tracing. No intervention is needed. The baseline fetal heart variability is the most important fetal heart assessment that the nurse makes. If the baby's heart rate shows average variability, the nurse can assume that the baby is not hypoxic or acidotic. In addition, the normal heart rate of 142 is reassuring.

89. The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station −2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

1. Thin cervix. During the labor process, however, the cervix changes shape, becoming paper thin and dilating to 10 cm. This is a universal finding. No matter how tall or short, old or young a woman is, her cervix will dilate to 10 cm and efface 100% if she has a vaginal delivery.

25. 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? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. This is the correct response. A fetal heart rate of 152 is normal. The normal fetal heart rate is 110 to 160 bpm. A rate of 152, therefore, is within normal limits. No further action is needed at this time.

68. A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

2. "I can't stand this pain any longer!"

37. A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

2. "You sound frightened."

78. A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

2. A wedge should be placed under one side of the woman. The test taker must remember that hypotension is the most common complication of epidural anesthe- sia in labor. One of the most important reasons for this is the compression of the vena cava by the pregnant uterus. When a wedge is placed under the woman's side— usually the right side—the uterus is tilted, relieving the pressure on the great vessels.

59. The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full- term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. 2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Baseline of 140 to 142 with no obvious decelerations or accelerations.

2. AbaselineFHof140to150isa baseline showing moderate, or normal, variability. Decelerations that mirror contractions are defined as early decelerations. These are related to head compression and are expected during transition and second stage labor. A baseline with beat to beat changes of only 2 bpm is defined as minimal variability. Also, there are late decelerations. Late decelerations are related to uteroplacental insufficiency. This situation is an obstetric emergency. A baseline fetal heart rate (FH) of 140 to 150 is a baseline with moderate variability, but V-shaped decelerations are variable decelerations. These are related to cord compression and are not normal.

"301. 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 electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Assess the baseline fetal heart rate. "Rationale: Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

53. The nurse wishes to assess the variability of the fetal heart rate. Which of the follow- ing actions is recommended prior to performing this assessment? 1. Place the client in the lateral recumbent position. 2. Insert an internal fetal monitor electrode. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

2. Before the variability can be accurately assessed, an internal fetal heart elec- trode should be applied. Only after assessing a poor fetal monitor tracing would the nurse administer oxygen. Variability is unrelated to fetal movement. Variability is the most important of the baseline data. Variability is a measure of the competition between the sympathetic nervous system, which speeds up the heart rate, and the parasympathetic nervous system, which slows down the heart rate. When the fetal heart variability is adequate, the nurse can conclude, therefore, that the baby's autonomic nervous system is healthy.

"305. The nurse is assisting a client undergoing induction of labor at 41 weeks' 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 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin (Pitocin). 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present. " Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Discontinue the infusion of oxytocin (Pitocin). "The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Applying oxygen, increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation. Contacting the client's primary support person(s) is not the priority action at this time." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

22. In addition to breathing with contractions, which of the following actions can help a woman in the first stage of labor to work with her pain? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2. Effleurage is a light massage that can soothe the mother during labor. Walking, swaying, and rocking can all help a woman during the process. Effleurage, the light massaging of the abdomen or thighs, is often soothing for the mothers.

60. A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2. Encourage the woman to grunt during contractions.

"293. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm3"

2. Fetal heart rate of 180 beats/minute "Rationale: A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery."

19. 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? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate.

2. Have the woman breathe into a bag. This client is light- headed as a result of being tachypneic during contractions. This fact is essential. Hyperventilation, which can result from tachypnea, is characterized by tingling and light-headedness. Rebreathing her air should rectify the problem.

3. 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? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2. The client is exhibiting an expected behavior for labor. The test taker must be familiar with the different phases of the first stage of labor: latent, active, and transition. The multiparous woman in the scenario entered the labor suite in the latent phase of labor when being talkative and excited is normal, but after 1 hour she has progressed into the active phase of labor in which being serious and breathing rapidly with contractions are expected behaviors.

48. An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

2. The fetal head has entered the true pelvis.

24. 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? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

66. A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

2. The woman is about to deliver the placenta. Although they sound abnormal, the following are the normal signs of placental separation: The uterus rises in the abdomen and becomes globu- lar, there is a gush of blood expelled from the vagina, and the umbilical cord lengthens. The placenta should be delivered between 5 and 30 minutes after the delivery of the baby.

71. A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variabil- ity and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2. The woman is in early labor. There is no need for her to be hospitalized at this time. The woman is clearly in the latent phase because she is only 2 cm dilated, 30% effaced, and is con- tracting infrequently at q 12 minutes with short duration. Plus, the fetal heart rate is excellent. She could be sent home to labor in comfort.

38. A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." This response indicates that the labor contractions are increasing in intensity. As labor progresses, the frequency of contractions decreases but the duration and the inten- sity, or strength, of the contractions increase. The nurse notes the change in intensity when he or she palpates the fundus of the uterus, and the client sub- jectively complains of increasing pain.

63. A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

3. "The baby is going to be born very soon. It is really too late for an epidural." Because this woman is a multipara, the position is LOA, and the station is +3, this is an accurate statement. The average length of the second stage of labor for multiparas is about 15 minutes, whereas the average time for an epidural to be inserted and to take effect is approximately 20 minutes. In addition, the fetus in the scenario has already descended to +3 station and is in the optimal position for delivery—LOA. It is very likely that this baby will be born in a few contractions. The nurse should en- courage the client to continue pushing with her contractions.

"294. The nurse is reviewing the record of a client in the labor room and notes that the"health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis"

3. 1 cm above the ischial spine "Rationale: Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine."

58. A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

3. Analgesics are central nervous system (CNS) depressants. The variability of the fetal heart rate, therefore, will be decreased.

31. 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? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3. 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.

62. A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's health care practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Continue to provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

3. Because this is a normal finding, the nurse should continue to provide labor support and encouragement. The bulging perineum is an indication that the baby is descending in the birth canal and the bloody show results from injury to the capillaries in the mother's cervix. Because this woman is a primigravida, she will likely need to push for many more minutes so it is not neces- sary to notify the health care provider until additional signs are noted.

74. On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is −2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

3. Delay pushing until the baby descends further and the mother has a strong urge to push. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis to birth the baby.

52. During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

3. During extension, the baby's head is birthed. Flexion is one of the first of the cardinal moves of labor. Internal rotation occurs while the baby is still in utero. The baby rotates externally after the birth of the head.

12. When performing Leopold's 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? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question. The fetal heart is best heard through the fetal back. Because, as determined by doing Leopold's maneu- vers, the baby is LOA, the fetal back (and, hence, the fetal heart) is in the left lower quadrant.

11. 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 in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

3. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain. During each contraction, the occiput, therefore, is forced backward into the coccyx. This action is very painful.

5. While performing Leopold's 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? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. 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. Many obstetric assess- ments have a component that is sensual and a component that is an interpretation or concept. Leopold's maneuvers are good examples. The nurse palpates specific areas of the pregnant abdomen, but then must interpret or translate what he or she is feeling into a concept. For example, in the scenario presented, the nurse palpates a hard, round mass in the fundal area of the uterus and must interpret that feeling as the fetal head. Similarly, the nurse palpates a soft round mass above the symphysis and must interpret that feeling as the fetal buttocks. With these findings and interpre- tations, the nurse will then realize that the fetal lie is vertical.

"302. 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? 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." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. "My contractions will increase in duration and intensity." "Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

42. The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

4. "The baby is almost crowning." The test taker should remember that a baby is crowning when the mother's perineal tissues are stretched around the fetal head at the same location where a crown would sit. The station at this time is past +5 station (or 5 cm past the ischial spines).

14. 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: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. 10 cm dilated, 100% effaced, and +5 station. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

40. A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4. A fetus in a scapular presentation is in a horizontal lie. Lie is concerned with the relationship between the fetal spine and the maternal spine. When the spines are parallel, the lie is vertical (or longitudinal). When the spines are perpendicular, the lie is horizontal (or transverse). It is physio- logically impossible for a baby in the horizontal lie to be delivered vaginally.

61. A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

4. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction. Holding the breath for 20 seconds during each contraction can stimulate the Valsalva maneuver, which can lead to a sudden drop in blood pressure and fainting. One cannot push and blow out at the same time. This will not facilitate the delivery of the baby. Pushing should be done only during contractions, not between contractions.

"300. 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 electronic fetal monitor 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 vital signs 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. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being." "Rationale: Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve."

21. 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? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing.

4. Encourage the woman to perform the next level breathing. Because the latent phase is the first phase of the first stage of labor, the contractions are usually mild and they rarely last longer than 30 seconds. A slow chest breathing technique, therefore, is effective and does not tire the woman out for the remainder of her labor.

26. 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? 1. After every contraction. 2. For 10 minutes every half hour. 3. Periodically during the peak of contractions. 4. For 1 minute immediately after contractions.

4. Intermittent auscultation should be performed for 1 full minute after contractions end. It is essential, however, that the fetal heart be monitored immediately after contractions for 1 full minute to identify the presence of any late or variable decelerations.

32. 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? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

4. Monitoring for rectal pressure is appropriate at this time. Although the test taker may see in practice that women are encouraged to begin to push as soon as they become fully dilated, it is best prac- tice to wait until the woman exhibits signs of rectal pressure. Pushing a baby that is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord.

55. After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

4. The fetus has a healthy nervous system. Moderate variability is indicative of fetal health. Normal situations that can decrease the variability include fetal sleep, administra- tion of central nervous system depressant medications, and prematurity. A normal situation that can increase the variability is fetal activity.

39. A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4. The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds. The test taker must recall that frequency is defined as the time from the beginning of one contrac- tion to the beginning of the next, while duration is defined as the beginning of the increment of a contraction to the end of the decrement. The only choices that include a frequency of 3 minutes are choices 3 and 4, whereas the only choice with a duration of 60 seconds is choice 4.

36. A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4. This client is exhibiting clear signs of true labor. Not only are the contrac- tions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen. Only when the woman is experiencing contractions that are increasing in intensity and dura- tion and decreasing in frequency, or when the woman has ruptured membranes, should she be encouraged to go to the hospital for an evaluation.