PassPoint - Intrapartum

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene?

60-79 beats per minute

After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which event occurs?

A sudden gush of dark blood appears.

A 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 they feel the need to have a bowel movement. What should the nurse do first?

Complete a vaginal examination.

A nurse is caring for a gravida 1, para 0 client at 40 weeks' gestation who is in active labor. The client's cervix is 5 cm dilated and 90% effaced; the fetal station is 0, and the fetus is in cephalic presentation. The baseline fetal heart rate is 135 bpm; it decreases to 125 bpm shortly after the onset of five uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first?

Document findings on the client's chart and continue to monitor labor progress.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time?

Instruct the partner on touch, massage, and breathing patterns.

When caring for a client with preeclampsia, which action is a priority?

Reducing visual and auditory stimulation

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?

Remain in a side-lying position with the head elevated.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed oxytocin intravenously after delivery of the placenta. Which sign would indicate to the nurse that the placenta is about to be delivered?

The cord lengthens outside the vagina.

Which statement describes the term fetal position?

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

The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. What is the nurse's priority intervention?

repositioning the client to the other side

A 24-year-old primigravid client in active labor asks to use the jet hydrotherapy tub to aid in pain relief. Which condition would the nurse consider to be a contraindication for hydrotherapy?

ruptured membranes

Which statement by the client indicates an understanding of teaching regarding the use of corticosteroids during preterm labor?

"The corticosteroids may help my baby's lungs mature."

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?

"What is your expected due date?"

A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: Give a 4-g bolus over 15 minutes, then decrease the rate to 2g/hour. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringer's on hand. What is the rate the nurse will set the pump to deliver the 2g maintenance dose? Record your answer using a whole number.

40

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time?

Ask the client what fluids she prefers to drink.

The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first?

Change the client's position.

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply.

Change the client's position. Contact the healthcare provider. Administer oxygen to the client.

The health care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction?

Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.

The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply.

Encourage ambulation. Suggest a shower or bath. Offer the use of a yoga ball.

A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action?

Offer to remain with the client while the partner takes a short break.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?

Place the client in the Trendelenburg position.

The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention?

Prepare for birth of the neonate.

A nurse is evaluating a fetal monitor strip and finds the fetal heart rate accelerated 20 beats per minute for 15 seconds. What is the nurse's best action?

Reassure the client that all is well with the fetus.

A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate?

Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born.

When the nurse is preparing the room for admission of a multigravida client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain?

padding for the side rails

A multigravid client is admitted to the labor area from the emergency department. At the time of admission, the fetal head is crowning and the client yells, "The baby is coming!" To help the client remain calm and cooperative during the imminent birth, which response by the nurse is most appropriate?

"I'll explain what is happening to guide you as we go along."

A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which would be a priority intervention by the nurse to establish whether the client can have an epidural?

Assess cervical dilation.

Two hours ago, a multigravid client was admitted in active labor with the cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on their lips, and extreme irritability. What should the nurse do first?

Assess the client's cervical dilation and station.

The nurse is caring for a pregnant client. The nurse notes hypotension and a non-reassuring fetal heart tracing. Which action would the nurse include in the client's plan of care?

Position the client on her left side.

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions?

Position to left lateral, O2 per nonrebreather mask at 10 L.

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to

a perinatologist.

The nurse determines that a client has an antenatal or intrapartum risk score of 2. Based on this information, which activity level should the nurse recommend to the client during labor?

ambulate as tolerated

The nurse is managing the 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 and pain level assessment every 30 minutes

The nurse is assisting with the birth of a fetus in a frank breech presentation. Which graphic illustrates that position?

both legs up lol

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation?

breech position

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?

chaplain, because his educational background includes strategies for handling grief

A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client?

complexity of care requirements

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the right occiput posterior position. The nurse should place the client in which position for pain relief?

hands and knees

The nurse is caring for a client at 36 weeks' gestation with a temperature of 101.2°F (38.4°C). Examination indicates that the client is leaking amniotic fluid. What is the nurse's priority concern based on these findings?

intrauterine infection

The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience what type of pain?

no pain

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

A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?

physician

The nurse hears a pregnant client yell, "Oh my! The baby is coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is being born. What should the nurse do first?

Check for presence of a cord around the neck.

A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?

Prepare the client and partner for a cesarean birth as soon as possible.

When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal system?

pulmonary

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first?

Assess the fetal heart rate (FHR) for 1 full minute.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony

The end of the third stage of labor is marked by what event?

delivery of the placenta

The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor?

when the placenta has been birthed

What action(s) does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply.

drying the newborn initiating skin-to-skin care taking newborn vital signs assigning the Apgar scores

The nurse is discussing pain relief methods for a pregnant first-time parent. The discussion should include which labor support method(s)? Select all that apply.

guided imagery pattern-paced breathing progressive relaxation effleurage

A 19-year-old primigravida at 38 weeks' gestation, in active labor for the past 8 hours, is admitted to the hospital accompanied by their parent. On admission, the client's cervix is 5 cm dilated, blood pressure is 120/84 mm Hg, and they are breathing rapidly and feeling dizzy and light-headed. The nurse determines that the client is most likely experiencing the effects of which condition?

hyperventilation

The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose?

increase in the fetal heart rate and variability

A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used.

increment acme decrement relaxation

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. The client's vital signs are: 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?

intravenous penicillin

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use?

light stroking of the skin surface

The nurse performs an assessment on a laboring client. The contractions are 3 minutes apart, 60 seconds duration, and of mild intensity for the past 4 hours. The client's cervix remains dilated at 5 cm and 100% effaced. Based on these findings, what plan of care does the nurse anticipate?

oxytocin augmentation

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to

prevent seizures.

The nurse is caring for a client in the first stage of labor. While observing the fetal heart monitor, the nurse notes a decrease in the fetal heart rate baseline starting after the peak of the contraction and ending after the contraction has ended. What does the nurse anticipate is the cause of the deceleration?

compromised uteroplacental perfusion

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is:

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.

The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention?

The membranes are intact.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply.

Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client.

A multiparous client is admitted to the labor and delivery area with painless vaginal bleeding. Ultrasonography shows that an edge of her placenta meets but doesn't occlude the rim of the cervical os. This finding suggests

marginal placenta previa.

A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?

shallow chest breathing

While caring for a client who has just given vaginal birth to a neonate, the nurse is monitoring for signs of placental separation. What signs indicate that the placenta has separated? Select all that apply.

sudden gush of vaginal blood change in shape of the uterus lengthening of the umbilical cord

A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?

time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR)

The nurse is explaining to a primagravida in labor that the baby is in a breech presentation, with the baby's presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how the baby is positioned?

upright baby

Which fetal presentation is most favorable for birth?

vertex presentation

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene?

Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction.

The nurse is caring for a client who is attempting a trial of labor (attempt a vaginal birth after cesarean). Contractions are 1.5 minutes apart with a duration 75 to 90 seconds. The client reports a "sharp, tearing" pain, and the electronic fetal monitor (EFM) is no longer recording contractions. What is the priority nursing action?

Prepare the client for an emergency cesarean birth.

A 30-year-old multigravid client pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when they say that an electronic monitor performs which function?

ensures a more comfortable atmosphere for the client and labor

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean birth. The client tells the nurse that they have been taking gingko biloba to help manage blood sugar. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication?

prolonged bleeding

A 16-year-old primigravid client admitted at 38 weeks' gestation with severe preeclampsia is given intravenous magnesium sulfate and lactated Ringer's solution. The nurse should obtain which information?

respiratory rate every hour

The nurse is caring for a client in the first stage of labor who states, "I am scared. The last time I gave birth, I was in labor for 32 hours, it was awful." What is the nurse's best response?

"Let's talk about options that can keep you more comfortable this time."

A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response?

"The baby needs to be observed more closely."