Silvestri Practice Questions

3.Increased efficiency of contractions 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord 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, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1.Less pressure on her cervix 2.Decreased number of contractions 3.Increased efficiency of contractions 4.The need for increased maternal blood pressure monitoring 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

2.July 26, 2019 Accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2018; subtract 3 months, July 19, 2018; add 7 days, July 26, 2018; add 1 year, July 26, 2019.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? 1.July 12, 2019 2.July 26, 2019 3.August 12, 2019 4.August 26, 2019

2.Every 15 minutes The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? 1.Hourly 2.Every 15 minutes 3.Every 30 minutes 4.Before each contraction

2.A fetal heart rate of 180 beats/min A normal fetal heart rate is 110 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased? 1.Increased urinary output 2.A fetal heart rate of 180 beats/min 3.Three contractions occurring in a 10-minute period 4.Adequate resting tone of the uterus palpated between contractions

1.Supine position with a wedge under the right hip 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 prone or semi Fowler's position is not practical for this type of abdominal surgery.

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

2."I will maintain strict bed rest throughout the remainder of the pregnancy." Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client should watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider.

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1."I will watch for the evidence of the passage of tissue." 2."I will maintain strict bed rest throughout the remainder of the pregnancy." 3."I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4."I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

1.Measure fundal height. Measuring fundal height is least appropriate because it should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1.Measure fundal height. 2.Attach electronic fetal monitoring. 3.Prepare the client for a possible cesarean section. 4.Visually examine the perineum and vaginal opening.

2.Continue to monitor the client. The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1.Contact the obstetrician. 2.Continue to monitor the client. 3.Report the FHR to the anesthesiologist. 4.Prepare for imminent delivery of the fetus.

1.A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1.A normal test result 2.An abnormal test result 3.A high risk for fetal demise 4.The need for a cesarean section

3.Explain to the client why a cesarean delivery is necessary. Because neonatal infection of HSV is life-threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal scrub will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms, not to eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1.Perform an abdominal scrub on the client. 2.Prepare the delivery room for a vaginal delivery. 3.Explain to the client why a cesarean delivery is necessary. 4.Call the health care provider to obtain a prescription for an antiviral medication.

3.Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). The client evidences progression toward delivery because the cervix is dilated 6 cm and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, her neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that IAP be administered during labor. Providing the client with instructions on pushing is not appropriate at a time when she does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore, the HCP is not required for delivery at this time.

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? 1.Provide the client with instructions on how to push. 2.Prepare the labor room and the client for an imminent delivery. 3.Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4.Call the HCP to the labor and delivery unit to perform a delivery.

2."The vaginal discharge may be bothersome, but is a normal occurrence." Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1."Come to the clinic immediately." 2."The vaginal discharge may be bothersome, but is a normal occurrence." 3."Report to the emergency department at the maternity center immediately." 4."Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

3.Inform the client that these contractions are common and may occur throughout the pregnancy. Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is no reason to notify the health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1.Contact the health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Inform the client that these contractions are common and may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.

2.Isoniazid plus rifampin will be required for 9 months. More than 1 medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1.Therapeutic abortion is required. 2.Isoniazid plus rifampin will be required for 9 months. 3.She will have to stay at home until treatment is completed. 4.Medication will not be started until after delivery of the fetus.

3.Increase in fundal height 4.Hard, boardlike abdomen 5.Persistent abdominal pain The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; hard, boardlike abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. 1.Back pain 2.Heavy vaginal bleeding 3.Increase in fundal height 4.Hard, boardlike abdomen 5.Persistent abdominal pain 6.Early deceleration on the fetal heart monitor

1.Delivery of the fetus The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining options are incorrect regarding management of the client with abruptio placentae.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for? 1.Delivery of the fetus 2.Strict monitoring of intake and output 3.Complete bed rest for the remainder of the pregnancy 4.The need for weekly monitoring of coagulation studies until the time of delivery

4.Administer oxygen at 8 to 10 L/min via face mask. Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The IV infusion should be increased, not decreased, so as to increase the maternal blood volume. The woman's position should be lateral with legs raised to increase maternal blood volume and improve the maternal vascular system.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? 1.Continue the oxytocin drip. 2.Slow the intravenous (IV) rate. 3.Place the client in a high Fowler's position. 4.Administer oxygen at 8 to 10 L/min via face mask.

1.The client is possibly in preterm labor. According to Nägele's rule, by subtracting 3 months and adding 7 days and 1 year to this client's LMP the nurse can determine that her estimated date of delivery (EDD) is April 14. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before her EDD; therefore, she is possibly in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation. This fetus is approximately 4 weeks before term. If this client truly is in labor, the health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery.

On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation? 1.The client is possibly in preterm labor. 2.The fetus may not be viable at delivery. 3.The client may require labor augmentation. 4.The fetus is at high risk for shoulder dystocia.

2.Periodic, early decelerations that indicate fetal head compression An early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described; therefore, eliminate option 3. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? 1.Episodic, late decelerations that indicate uteroplacental insufficiency 2.Periodic, early decelerations that indicate fetal head compression 3.Periodic, variable decelerations that indicate cord compression 4.Episodic, early decelerations that may be a result of maternal hypotension

1.The client has a history of intravenous drug use. 3.The client has a history of sexually transmitted infections. HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1.The client has a history of intravenous drug use. 2.The client has a significant other who is heterosexual. 3.The client has a history of sexually transmitted infections. 4.The client has had one sexual partner for the past 10 years. 5.The client has a previous history of gestational diabetes mellitus.

2.Moderate variability present Reassuring signs in the fetal heart tracing include an FHR of 110 to 160 beats/minute, accelerations of the FHR, no variable decelerations, and the presence of moderate variability. The moderate variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations indicate cord compression.

The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? 1.No accelerations of fetal heart rate (FHR) 2.Moderate variability present 3.Variable decelerations present 4.FHR of 170 to 180 beats/minute

1.Proteinuria 2.Hypertension The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur, but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.Proteinuria 2.Hypertension 3.Low-grade fever 4.Generalized edema 5.Increased pulse rate 6.Increased respiratory rate

4.The client complains of a headache and blurred vision. If the client complains of a headache and blurred vision, the HCP should be notified, because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? 1.Urinary output has increased. 2.Dependent edema has resolved. 3.Blood pressure reading is at the prenatal baseline. 4.The client complains of a headache and blurred vision.

4.Monitoring the mother's blood pressure A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

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? 1.Assessing the mother's reflexes 2.Taking the mother's temperature 3.Taking the mother's apical pulse 4.Monitoring the mother's blood pressure

1.Petechiae 2.Hematuria 4.Prolonged clotting times 5.Oozing from injection sites DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. The presence of petechiae, hematuria, and oozing from injection sites are signs associated with DIC. Swelling and pain in the calf of 1 leg are more likely to be associated with thrombophlebitis.

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1.Petechiae 2.Hematuria 3.Increased platelet count 4.Prolonged clotting times 5.Oozing from injection sites 6.Swelling of the calf of 1 leg

2.Obtain equipment for a manual pelvic examination. Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1.Prepare the client for an ultrasound. 2.Obtain equipment for a manual pelvic examination. 3.Prepare to draw a hemoglobin and hematocrit blood sample. 4.Obtain equipment for external electronic fetal heart rate monitoring.

4.Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.

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? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation

4.Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings.

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse should document these observations as signs of which condition? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation

1.Assess the fetal heart rate. After amniotomy or rupture of the membranes in the birth setting, the nurse immediately assesses the fetal heart rate for at least 1 minute to detect changes associated with prolapse or compression of the umbilical cord. The quantity, color, and odor of the amniotic fluid also are noted. The client's temperature should be assessed every 2 to 4 hours, and the nurse also should check the client's vital signs. The pads under the client should be changed regularly to promote comfort and reduce the moist environment that favors bacterial growth, but this is not the priority.

The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1.Assess the fetal heart rate. 2.Check the client's temperature. 3.Change the pads under the client. 4.Check the client's respiratory rate.

3."It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage.

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? 1."It is the application of pressure to the sacrum to relieve a backache." 2."It is a form of biofeedback to enhance bearing-down efforts during delivery." 3."It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4."It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."

2.Rest between contractions 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. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1.Ambulation 2.Rest between contractions 3.Change positions frequently 4.Consume oral food and fluids

2.Monitoring the fetal heart rate Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1.Providing comfort measures 2.Monitoring the fetal heart rate 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor

3."I should avoid exercise because of the negative effects on insulin production." Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or HCP's office. Signs of infection need to be reported to the HCP.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1."I should stay on the diabetic diet." 2."I should perform glucose monitoring at home." 3."I should avoid exercise because of the negative effects on insulin production." 4."I should be aware of any infections and report signs of infection immediately to my health care provider (HCP)."

4.Persistent nonreassuring fetal heart rate Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1.Maternal fatigue 2.Coordinated uterine contractions 3.Progressive changes in the cervix 4.Persistent nonreassuring fetal heart rate

4.Complaints of severe abdominal pain Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1.Chest pain 2.A rigid abdomen 3.A soft and boggy uterus 4.Complaints of severe abdominal pain

2."I need to lie flat on my back to perform the procedure." The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the health care provider (HCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the HCP.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1."I will record the number of movements or kicks." 2."I need to lie flat on my back to perform the procedure." 3."If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." 4."I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

1.Forceps delivery Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1.Forceps delivery 2.Schultz presentation 3.Hypotonic contractions 4.Weak bearing-down efforts

1.Provide pain relief measures. Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Promote ambulation every 30 minutes. 4.Monitor the oxytocin infusion closely.

2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida II who has just been diagnosed with dead fetus syndrome 4.A gravida IV who delivered 8 hours ago and has lost 500 mL of blood In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1.A primigravida with mild preeclampsia 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida II who has just been diagnosed with dead fetus syndrome 4.A gravida IV who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

1.Administer oxygen via face mask. 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.

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 intravenous infusion. 4.Document the findings and continue to monitor the fetal patterns.

4.Document the findings and continue to monitor fetal patterns. Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, contacting the HCP, changing the client' position, or administering oxygen is not necessary.

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1.Contact the health care provider (HCP). 2.Place the client in Trendelenburg's position. 3.Administer oxygen to the client by face mask. 4.Document the findings and continue to monitor fetal patterns.

3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." Intravenous medication should be administered slowly in small doses starting at the beginning of a contraction and carrying over for 3 to 5 contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. The statements in the remaining options are incorrect information about the medication effects.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1."The medication will affect you and your pain level only when given during a contraction." 2."The medication will provide optimal relief when it is given while your pain level is highest." 3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4."You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

2.Assess the baseline fetal heart rate. 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.

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.

2.Uterine tenderness Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1.Soft abdomen 2.Uterine tenderness 3.Absence of abdominal pain 4.Painless, bright red vaginal bleeding

1."I will need to increase my insulin dosage during the first 3 months of pregnancy." Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1."I will need to increase my insulin dosage during the first 3 months of pregnancy." 2."My insulin dose will likely need to be increased during the second and third trimesters." 3."Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4."My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1.Oxytocin infusion Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. The remaining options identify therapeutic measures for a client with hypertonic dysfunction.

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and should expect to note which prescribed treatment for this condition? 1.Oxytocin infusion 2.Increased hydration 3.Administration of a tocolytic medication 4.Administration of a medication that will provide sedation

2.Discontinue the infusion of oxytocin. 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. Notifying the health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 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. 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.

1.Clear, dark amber amniotic fluid 3.Light green amniotic fluid with no odor 4.Thick white amniotic fluid with no odor Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin, watery consistency and may have a mild odor. The normal amount of amniotic fluid ranges from 500 to 1000 mL. Dark amber color, light green color, and thick white color are not descriptions of normal amniotic fluid and should be brought to the HCP's attention.

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply. 1.Clear, dark amber amniotic fluid 2.Amniotic fluid volume of 800 mL 3.Light green amniotic fluid with no odor 4.Thick white amniotic fluid with no odor 5.Straw-colored amniotic fluid with flecks of vernix

1.Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To facilitate oxygen to the mother and her fetus, the client is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action? 1.Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. 2.Turn the client on her back and administer oxygen by face mask at 8 to 10 L/min. 3.Turn the client on her side and administer oxygen by nasal cannula at 2 to 4 L/min. 4.Turn the client on her back and administer oxygen by nasal cannula at 2 to 4 L/min.

1.Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned onto her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is then applied to the mother.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? 1.Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2.Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3.Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4.Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.

3.Encourage an upright or side-lying maternal position. Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations, without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? 1.Prepare the client for a cesarean delivery. 2.Monitor the FHR every 30 minutes. 3.Encourage an upright or side-lying maternal position. 4.Increase the rate of the oxytocin infusion every 10 minutes.

4.Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. 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. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.

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.

3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into 4 different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. 1.Early labor 2.Amniotomy 3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies

3.Palpating the maternal radial pulse while listening to the FHR The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the 2 heart rates.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1.Noting whether the heart rate is greater than 140 beats/minute 2.Placing the diaphragm of the Doppler on the mother's abdomen 3.Palpating the maternal radial pulse while listening to the FHR 4.Performing Leopold's maneuvers first to determine the location of the fetal heart

2.A fetal heart rate of 90 beats/minute A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress.

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? 1.Increased urinary output 2.A fetal heart rate of 90 beats/minute 3.3 contractions occurring within a 10-minute period 4.Adequate resting tone of the uterus palpated between contractions

3.The cervix is dilated completely. 5.The spontaneous urge to push is initiated from perineal pressure. The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

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. 1.The contractions are regular. 2.The membranes have ruptured. 3.The cervix is dilated completely. 4.The client begins to expel clear vaginal fluid. 5.The spontaneous urge to push is initiated from perineal pressure.

1.Administering oxygen via face mask Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned on her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Documenting and monitoring would delay necessary treatment.

The nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding, the nurse should prepare for which appropriate nursing action? 1.Administering oxygen via face mask 2.Placing the mother in a supine position 3.Increasing the rate of the intravenous (IV) oxytocin infusion 4.Documenting the findings and continuing to monitor the fetal patterns

4.Fear of losing control Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1.Exhaustion 2.Valsalva maneuver 3.Involuntary grunting 4.Fear of losing control

2.Breathe rapidly. During a precipitous labor, when the infant's head crowns the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1.Bear down. 2.Breathe rapidly. 3.Hold your breath. 4.Push with each contraction.

1.Stop the oxytocin infusion. Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse should monitor the client's blood pressure and intake and output; however, the nurse should first stop the infusion.

The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1.Stop the oxytocin infusion. 2.Check the client's blood pressure. 3.Check the client for bladder distention. 4.Place the client in a side-lying position.

Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity if past 20 weeks of gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1.G = 3, T = 2, P = 0, A = 0, L = 1 2.G = 2, T = 1, P = 0, A = 0, L = 1 3.G = 1, T = 1, P = 1, A = 0, L = 1 4.G = 2, T = 0, P = 0, A = 0, L = 1

3."It promotes the fertilized ovum's normal implantation in the top portion of the uterus." The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1."It promotes the fertilized ovum's chances of survival." 2."It promotes the fertilized ovum's exposure to estrogen and progesterone." 3."It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4."It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

1.Monitoring fetal status The priority in the plan of care should include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.

The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? 1.Monitoring fetal status 2.Providing comfort measures 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor

1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated.

1.Notify the health care provider (HCP). 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.

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.Determine the fetal heart rate. When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Taking the blood pressure and noting the characteristics of the amniotic fluid are also appropriate actions, but are not the initial actions in this situation. The nurse may assist the client in cleaning, changing clothing, and providing peripads, but determining the fetal heart rate is the initial action.

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1.Determine the fetal heart rate. 2.Provide peripads for the client. 3.Take the client's blood pressure. 4.Note the amount, color, and odor of the amniotic fluid.

4.Variable decelerations 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.

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

1.Age 54 2.Body mass index of 28 3.Previous difficulty with fertility Risk factors that increase a woman's risk for dysfunctional labor include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with infertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1.Age 54 2.Body mass index of 28 3.Previous difficulty with fertility 4.Administration of oxytocin for induction 5.Potassium level of 3.6 mEq/L (3.6 mmol/L)

2.The passage of meconium Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate; fetal acidosis; and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? 1.Maternal fatigue 2.The passage of meconium 3.Coordinated uterine contractions 4.Progressive changes in the cervix

2.Fetal heart rate of 180 beats/minute 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 11-13 g/dL (110-130 mmol/L) ) 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 mm3 (11 to 15 x 10 9/L), up to 18,000 mm3 (18 x 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 x 109/L) because of increased leukocytosis that occurs during delivery.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? 1.Hemoglobin of 11 g/dL (110 mmol/L) 2.Fetal heart rate of 180 beats/minute 3.Maternal pulse rate of 85 beats/minute 4.White blood cell count of 12,000 mm3 (12.0 × 109/L)

3.The client is measuring normal for gestational age. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1.The client is measuring large for gestational age. 2.The client is measuring small for gestational age. 3.The client is measuring normal for gestational age. 4.More evidence is needed to determine size for gestational age.

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

3.Notify the health care provider (HCP). The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP). 4. Tell the client that the fetal heart rate is normal.

1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Positive pregnancy test The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Positive pregnancy test 5.Fetal heart rate detected by a nonelectronic device 6.Outline of fetus via radiography or ultrasonography

4.Evidence of bleeding, such as in the gums, petechiae, and purpura Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura

2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 5.Thromboembolism stockings or sequential compression devices may be prescribed. The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, will likely be prescribed due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1.Bed rest as a necessary preventive measure may be prescribed. 2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.

3.Butorphanol tartrate Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1.Fentanyl 2.Morphine sulfate 3.Butorphanol tartrate 4.Meperidine hydrochloride

3.Continuous electronic fetal monitoring Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question that indicate the need for antibiotics or complete bed rest. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion.

The nurse is preparing to care for a client in labor. The health care provider (HCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion? 1.An IV infusion of antibiotics 2.Placing the client on complete bed rest 3.Continuous electronic fetal monitoring 4.Placing a code cart at the client's bedside

3.Continuous electronic fetal monitoring Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? 1.An IV infusion of antibiotics 2.Placing the client on complete bed rest 3.Continuous electronic fetal monitoring 4.Placing a code cart at the client's bedside

1.Provide pain relief measures. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes amniotomy and oxytocin augmentation to stimulate a labor that slows. The client with hypertonic uterine dysfunction should not be encouraged to ambulate every 30 minutes but should be encouraged to rest.

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Monitor the oxytocin infusion closely. 4.Promote ambulation every 30 minutes.

1.The client's fear The mother is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. There are no data in the question to support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience.

The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? 1.The client's fear 2.The client's fatigue 3.The client's inability to control the situation 4.The client's inability to cope with the situation

3.An informed consent needs to be signed before the procedure. Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1.Strict bed rest is required after the procedure. 2.Hospitalization is necessary for 24 hours after the procedure. 3.An informed consent needs to be signed before the procedure. 4.A fever is expected after the procedure because of the trauma to the abdomen.

4."I should drink adequate fluids and increase my intake of high-fiber foods." Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium should be restricted as prescribed by the health care provider because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1."I should increase my sodium intake during pregnancy." 2."I should lower my blood volume by limiting my fluids." 3."I should maintain a low-calorie diet to prevent any weight gain." 4."I should drink adequate fluids and increase my intake of high-fiber foods."

3.Perform a vaginal examination every shift. Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1.Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. 3.Perform a vaginal examination every shift. 4.Administer an antibiotic per HCP prescription and per agency protocol.

4."My contractions will increase in duration and intensity." True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) 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.

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."

2.Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the HCP and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1.Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the health care provider (HCP) stat. 4.Call the delivery room to notify the staff that the client will be transported immediately.

2.Clear and maintain an open airway. The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1.Administer oxygen by face mask. 2.Clear and maintain an open airway. 3.Administer magnesium sulfate intravenously. 4.Assess the blood pressure and fetal heart rate.

2."Your type of pelvis is the most favorable for labor and birth." A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1."Your type of pelvis has a narrow pubic arch." 2."Your type of pelvis is the most favorable for labor and birth." 3."Your type of pelvis is a wide pelvis, but it has a short diameter." 4."You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function 5.Prevents large particles such as bacteria from passing to the fetus 6.Provides an exchange of nutrients and waste products between the mother and the fetus

3.Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.

Which assessment following an amniotomy should be conducted first? 1.Cervical dilation 2.Bladder distention 3.Fetal heart rate pattern 4.Maternal blood pressure

1."I feel like I need to push." The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. At this time, the laboring woman typically experiences the desire to push. Contractions becoming stronger are experienced throughout labor and do not indicate that she has reached stage 2. Having several minutes to rest between contractions does not describe the end of transition. Leaking of amniotic fluid does not mean that she is completely dilated.

Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? 1."I feel like I need to push." 2."My contractions seem to be getting stronger." 3."I am glad that I have several minutes to rest between contractions." 4."Warm fluid is running down my legs each time I have a contraction."

2."Do you plan to have any other children?" Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? 1."Did you ever had surgery?" 2."Do you plan to have any other children?" 3."Do either of you have diabetes mellitus?" 4."Do either of you have problems with high blood pressure?"

4.Painless vaginal bleeding The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of abruptio placentae.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? 1.Back pain 2.Abdominal pain 3.Painful vaginal bleeding 4.Painless vaginal bleeding

1.Palpate the bladder at frequent intervals. The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses the sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus. Hypotension, not hypertension, is a concern.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed? 1.Palpate the bladder at frequent intervals. 2.Encourage the woman to walk to progress the labor. 3.Assess the blood pressure frequently for hypertension. 4.Encourage the woman to assume a supine position after the epidural has been placed.

2.Assess the vagina and cervix with a gloved hand. It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1.Reposition the laboring woman to knee-chest. 2.Assess the vagina and cervix with a gloved hand. 3.Notify the health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes.

4.Pale straw in color, with flecks of vernix Amniotic fluid normally is pale straw in color and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white; this could be an indication of infection.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? 1.Light green, with no odor 2.Clear and dark amber in color 3.Thick and white, with no odor 4.Pale straw in color, with flecks of vernix

2.Prevent dehydration and hypoxemia. A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration.

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1.Stimulate the labor process. 2.Prevent dehydration and hypoxemia. 3.Avoid the necessity of a cesarean section. 4.Eliminate the need for analgesic administration.

4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute. Maternal hypotension results in decreased placental perfusion, so the focus of nursing care should be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, as she just received an epidural which is typically administered at 6 cm or earlier dilation, so option 1 can be eliminated. Administering a tocolytic can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Administering an opioid antagonist can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1.Prepare for delivery. 2.Administer a tocolytic. 3.Administer an opioid antagonist. 4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute.

1.Assess for signs and symptoms of labor. As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1.Assess for signs and symptoms of labor. 2.Assess the client's temperature every 2 hours. 3.Schedule a daily ultrasound to assess fetal movement. 4.Schedule a nonstress test every 4 hours to assess fetal well-being.

3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus. The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1.It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.