test 2
A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?
Elevate the head of the bed.
A multigravida client at 39 weeks' gestation has been in labor for 8 hours without much change. The last vaginal exam revealed cervix 8 cm dilated and zero station. Which is the best response if the client asks the nurse how far the fetus has advanced in the past half hour?
"Once your labor signs change, we can find out
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on an assessment?
1 cm below the umbilicus
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?
110 to 160 bpm
The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?
Encourage her through the contractions, explaining why she cannot receive any pain medication.
A client has moved into the active phase of labor and is now at 6 cm dilated and station . The nurse is prepared to monitor the contraction pattern how often ?
Every 30 minutes
A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?
Anxiety can slow down labor and decrease oxygen to the fetus.
A young couple is very excited to discover they are pregnant and asks the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery?
April 27
The client is asking the nurse about the various options for pain relief and requests more information about the intradermal water injection her sister had. When explaining the procedure the nurse should point out these injections are given at which location?
Lower back
You advise your pregnant patient to keep a small high-carbohydrate snack on the bedside table. This advice is given to ameliorate which condition?
Nausea and vomiting
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording?
Acceleration of at least 15 bpm for 15 seconds
The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client?
Acute pain related to uterine contractions
A client has just received IV sedation. What must the nurse tell the client to do?
Ambulate only with assistance from the nurse or caregiver.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
fetal status
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure?
Amniocentesis
A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia insead of an epidural. Which medication will the nurse prepare to give the client first?
Antacid
The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize?
Be certain she is aware of potential complications.
The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation?
Beginning attachment and preparation for family
The nurse is assessing a client who has just given birth and notes her prelabor vital signs reveal a temperature 98.8oF (37.1oC), blood pressure 120/70 mm Hg, HR 80, and RR 20. Which current vital sign assessment should the nurse prioritize?
Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min.
A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?
Body secreting the excess fluids from pregnancy
A 38 -year -old client and partner are carriers of the Tay- Sachs gene, have one child with Tay- Sachs. and are concerned to leam she is pregnant again. The nurse predicts the health care provider will order which test if the couple wants to know if this baby will also be born with Tay- Sachs?
Chorionic villas sampling
The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4, three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry?
Clear liquids but no solid food
The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?
Continue this as long as she enjoys it.
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?
Continuous labor support
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be the most effective at this point?
Counter Pressure against the sacrum
The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize?
Do not to attempt another pregnancy for at least 3 months.
The nursing instructor has completed a session on the induction of labor and how it is occurring more frequently. The instructor determines the session is successful when the students correctly choose which factor to be contributing to the increased induction rates?
Elective inductions by choice of both physician and client
The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?
Engorgement
The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?
Fear of pain during labor
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?
Fetal position
During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent, and the baseline FHR is within normal limits. What should the nurse do first?
Help the woman change positions.
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client?
Increasing fluid intake
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?
Just before birth
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and 'ready to see the baby.' The nurse interprets this to mean the client is in which stage or phase of labor?
Latent phase
The pregnant client and her partner have arrived for a scheduled cesarean delivery. Which action should the nurse prioritize?
Obtain laboratory specimens
The nursing instructor is leading a group discussion on the various types of delivery. The instructor determines the session is successful when the students correctly categorize forceps or vacuum-assisted delivery as what type?
Operative vaginal delivery
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack.
The nursing instructor is teaching a session on how labor starts. The instructor determines the session is successful when the class correctly chooses which causative factor that initiates labor?
Prostaglandins may be the causative factor of labor.
The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?
Provide care under the supervision of an RN.
A woman dilated to 10 centimeters and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?
Pudendal block
A multigravida woman arrives in the emergency department panting and screaming, 'The baby's coming!' Which action should the nurse prioritize?
Quickly evaluate the perineum.
A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?
Rest when possible with feet elevated at or above the heart.
The nurse is monitoring a client and notes: contractions every 2 to 3 minutes, duration 45 to 60 seconds, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?
Second
The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction?
Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85
The health care provider has determined a client should be admitted for induction of labor and begins the process with cervical ripening overnight. Which teaching should the nurse prioritize for the client and her partner when describing this procedure?
The cervix needs to be soft and thinning to be induced for labor; this helps soften the cervix.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?
The client reports back pain, and the cervix is effacing and dilating.
The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting?
Watch it and report if heavy increase in bleeding.
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?
Wear a tight, supportive bra.
The nursing instructor has finished leading a general discussion with a group of nursing students exploring the labor and birthing process. The instructor determines the session is successful when the students correctly state which goal should be a priority?.
Work with the labor client to plan pain management options
