Pregnancy, Labor, Childbirth, Postpartum - Uncomplicated
After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond?
"I'll get you some warm blankets to help make the chill go away."
The coach of a primigravida who has been in active labor for about 6 hours asks the nurse, "How much longer will this take? She's having a lot of back pain, and she's so uncomfortable." How should the nurse respond?
"Let me show you how to apply back pressure."
A 23-year-old primigravida is at her first prenatal appointment today. Ultrasound indicates that she is at 9 weeks' gestation. She asks when she can first expect to feel her baby move. The best response by the nurse is:
"Many women are able to first feel light movement between 18 and 20 weeks."
A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?
Auscultating the fetal heart
The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located?
Below the ischial spines
What finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.6° C) and 97.4° F (36.3° C) would be considered critical?
Blood glucose level of 36 mg/dL
A client is bleeding excessively after the birth of a neonate. The health care provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin (Pitocin) at a rate of 100 mL/hr. A nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action?
Checking for a distended bladder
External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?
Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends
A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?
Explain why this is expected in early pregnancy.
What is the primary outcome for client care in the third stage of labor?
Firmly contracted uterine fundus
A nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify?
First
A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram?
Increase fluid intake for 1 hour before the procedure.
A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear?
Low-heeled shoes
A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply.
Maintaining intravenous fluid administration Having oxygen available in case of hypotension Checking the bladder for distention every 2 hours Monitoring fetal heart rate and labor progress per hospital protocol
What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply
Pain management with oral analgesics Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals
A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response in language the client will understand?
Peripheral vasomotor activity is promoted.
What does a nurse explain to a pregnant client about the cause of her physiologic anemia?
Plasma volume increases.
A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented?
Precipitous vaginal delivery
During labor the nurse encourages the client to void periodically. The nurse knows that an overdistended urinary bladder during labor can:
Predispose the client to uterine hemorrhage after birth
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at −1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse do next?
Provide the client with comfort measures used for women in labor.
A nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client?
Semi-Fowler position to avoid hypotension
A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?
The cervix is dilated.
What should a nurse include in the discharge teaching of a postpartum client?
The prenatal Kegel tightening exercises should be continued.
A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result?
This is the desired response at this stage of gestation
A vaginal examination reveals that a client in labor is dilated 8 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering?
Transition
Before a postpartum client is discharged, the nurse advises her about problems that should be reported and then asks her to recall these problems. Identification of which problem identified by the client indicates that the teaching has been effective?
Urgency, frequency, and burning on urination
In a childbirth preparation class the instructor teaches the women to control their urge to push until the cervix is fully dilated. Which action does the nurse teach that will help control the urge to push?
Using panting and blowing breathing patterns
At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?
Uteroplacental insufficiency
A pregnant client is being prepared for a pelvic examination. She reports that she is always tired and feels sick to her stomach, especially in the morning. What is the best response by the nurse?
"Let's discuss ways to resolve these common problems."
A client at 38 weeks' gestation is scheduled for a nonstress test. The woman asks the nurse, "Do you think this test is necessary?" How should the nurse reply?
"You seem to have doubts about this test."
A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?
Meperidine (Demerol)
A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor?
Midway through first stage of labor
The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains?
Multipara who has vaginally delivered three children
The nurse is preparing a client in active labor for epidural anesthesia. Which prescribed intervention should the nurse initiate before the anesthesiologist administers the epidural?
Administering a 500-mL bolus of lactated Ringer's solution intravenously
