13. Intrapartum Complications & Procedures

hypotonic contractions

weak, inefficient, or completely absent

normal FHR

110-160 beats/min

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. Tachycardia 4. Fetal hypoxia 5. Metabolic acidemia 6. Congenital anomalies NCLEX

The nurse is caring for a laboring client with sickle cell anemia. Which therapy should the nurse anticipate the primary healthcare provider ordering? a. Oxygen b. Diuretics c. Magnesium sulfate d. Bronchodilators

a. Oxygen text

fetal tachycardia

-FHR >160 beats/min for 10 min or more -marked tachycardia = FHR >180 beats/min

fetal bradycardia interventions (3)

-administer oxygen -assist mother to side-lying position -discontinue oxytocin

prolapsed umbilical cord risk factors: fetal (4)

-fetal malpresentation -unengaged vertex -prematurity -small for gestational age

preterm labor risk factors (9)

-multifetal pregnancy -age <17 yrs or >35 yrs -diabetes -hypertension, preeclampsia -placenta previa -abruptio placentae -UTI -hydramnios (excessive amniotic fluid) -smoking, drug use

prolapsed umbilical cord risk factors: maternal pregnancy-related (4)

-multiple gestation -multiparity -polyhydramnios (↑ amniotic fluid) -ROM (spontaneous or artificial)

vacuum-assisted and forceps delivery conditions for use (4)

-vertex presentation -ruptured membranes -absence of cephalopelvic disproportion -fully dilated cervix

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

1. Petechiae 2. Hematuria 4. Prolonged clotting times 5. Oozing from injection sites NCLEX

amnioinfusion

infusion of normal saline or lactated Ringer's into the amniotic cavity to supplement the amount of amniotic fluid

episodic FHR variability

not associated with uterine contractions

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

1. Administer oxygen via face mask. (Late decelerations = uteroplacental insufficiency, decreased blood flow and oxygen to fetus - administer oxygen, side-lying position, stop oxytocin infusion) NCLEX

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. The passage of meconium (Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate; fetal acidosis; and the passage of meconium) NCLEX

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

3. Increased efficiency of contractions 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord NCLEX

fetal bradycardia

FHR <110 beats/min for 10 min or more

A nurse is admitting a laboring client with a breech presentation. Which complication occurs more frequently in the setting of breech presentation? a. Cord prolapse b. Neonatal hypoglycemia c. Respiratory distress d. Retained placenta

a. Cord prolapse text

amniotomy risks (2)

-prolapsed umbilical cord -infection

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor

1. Hypotonic NCLEX

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 would expect to note which prescribed treatment for this condition? 1. Increased hydration 2. Oxytocin infusion 3. Administration of a tocolytic medication 4. Administration of a medication that will provide sedation

2. Oxytocin infusion (to stimulate/augment labor) NCLEX

Which assessment finding indicates that the client is at risk for preterm labor? 1. client is a 35-yr-old primigravida 2. client has a history of cardiac disease 3. client's hemoglobin is 13.5 g/dL 4. client is a 20-yr-old primigravida of average weight and height

2. client has a history of cardiac disease NCLEX

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would 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. Persistent nonreassuring fetal heart rate NCLEX

A nurse in L&D is completing an admission assessment for a client who is at 39 weeks gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios

B. Infection (rupture of membranes for >24 hr prior to delivery increases risk of infection) ATI

A nurse is caring for a client admitted to the birthing unit with rupture of membranes for 2 hours. A pelvic exam reveals a dilatation of 4 cm, and the presenting part is not engaged. Which possible complication should the nurse anticipate? a. Prolapsed cord b. Placenta previa c. Amniotic infection d. Abruptio placentae

a. Prolapsed cord text

amniotomy

artificial rupture of membranes

periodic FHR variability

associated with uterine contractions

A laboring client complains of numbness of nose, fingers, and toes, and spots before her eyes. What should be the initial action by the nurse? a. Implement seizure precautions. b. Encourage slow, shallow breaths. c. Administer oxygen at 5 L per minute. d. Notify the primary healthcare provider or nurse-midwife.

b. Encourage slow, shallow breaths. text

A client is diagnosed with preterm labor at 28 weeks' gestation. She asks the nurse what is going to happen to her baby if she is born now. The nurse's responses are based on the knowledge that the most significant problems for this infant will be associated with: a. Low birth weight. b. Feeding problems. c. Lung maturity. d. Skeletal injuries.

c. Lung maturity. text

A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus is at risk for developing? a. intrauterine growth restriction b. hyperglycemia c. meconium aspiration d. polyhydramnios

c. meconium aspiration ATI

A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? a. Precipitous labor b. Premature rupture of membranes c. Postmaturity syndrome d. Prolapsed umbilical cord

d. Prolapsed umbilical cord ATI

vacuum-assisted and forceps delivery complications (6)

-facial nerve palsy -brachial plexus injury -facial bruising, lacerations -caput seccedaneum -cephalohematoma -maternal lacerations (cervix, vagina, perineum)

PROM risks (2)

-infection -prolapsed umbilical cord

medications for preterm labor (3)

-magnesium sulfate (tocolytic) -nifedipine (calcium channel blocker, tocolytic) -betamethasone (fetal lung development)

fetal tachycardia causes (6)

-maternal or fetal infection -maternal dehydration -maternal hyperthyroidism -cocaine or methamphetamine use -fetal anemia -fetal hypoxia

dystocia risk factors (5)

-overweight -age >40 yrs -cephalopelvic disproportion -multifetal pregnancy -dehydration

variable deceleration interventions (3)

-place pt in side-lying position -administer oxygen -discontinue oxytocin

late deceleration interventions (4)

-place pt in side-lying position (weight off vena cava) -administer oxygen -increase rate of IV fluids (offset hypotension) -discontinue oxytocin

vacuum-assisted and forceps delivery indications (4)

-prolonged labor -maternal exhaustion -ineffective pushing efforts -fetal distress

dystocia

-prolonged, difficult labor -atypical uterine contractions fail to efface and dilate cervix

early decelerations

-slowing of FHR with start of contraction with return of FHR to baseline at end of contraction -occur during contraction from fetal head compression -normal: not associated with fetal compromise, requires no intervention

fetal bradycardia causes (6)

-uterine hyperstimulation -umbilical cord compression -maternal hypotension -fetal congenital heart block -abruptio placentae -maternal hypothermia

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

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility (risk factors: 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) NCLEX

A 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.

1. Assess the fetal heart rate. NCLEX

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. Clear, dark amber amniotic fluid 3. Light green amniotic fluid with no odor 4. Thick white amniotic fluid with no odor -normal = pale straw color and may contain flecks of vernix caseosa -normal = thin, watery consistency and may have a mild odor -normal amount = 500-1000 mL. NCLEX

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. Forceps delivery NCLEX

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.

1. Measure fundal height. (should be measured at each antepartum clinic visit, not in the intrapartum period) NCLEX

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

1. Notify the health care provider (HCP). (fetal bradycardia between contractions may indicate the need for immediate medical management) NCLEX

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.

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.) NCLEX

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.

1. Stop the oxytocin infusion. NCLEX

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1. Supine position with a wedge under the right hip NCLEX

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.

1. The client is possibly in preterm labor. (Nagele's rule = EDD April 14. Pt is in L&D unit to be evaluated for the presence of labor more than 1 month before her EDD; therefore, she is possibly in preterm labor.) NCLEX

A 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

1. The client's fear (no data to support a client problem with fatigue, inability to control the situation, or inability to cope with the situation) NCLEX

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.

1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. (fetal distress, need to promote adequate oxygenation) NCLEX

prolapsed umbilical cord interventions (7)

1. call for assistance 2. reposition pt: Trendelenburg, ass-up 3. elevate fetal presenting part off cord using fingers 4. apply warm, sterile, saline-soaked towel to visible cord (prevents drying, maintains blood flow) 5. administer oxygen (improves fetal oxygenation) 6. IV fluids 7. prepare for c-section

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.

2. Assess the vagina and cervix with a gloved hand. (assess for a prolapsed cord) NCLEX

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

2. Clear and maintain an open airway. (seizures) NCLEX

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin. 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.

2. Discontinue the infusion of oxytocin. NCLEX

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

2. Fetal heart rate of 180 beats/minute (normal FHR = 110-160 bpm, 180 bpm indicates fetal distress) NCLEX

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

2. Monitoring the fetal heart rate NCLEX

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 is 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

2. Periodic, early decelerations that indicate fetal head compression (periodic = associated with contractions) NCLEX

A 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 stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

2. Place the client in Trendelenburg's position. NCLEX

During the intrapartum period, a 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 delivery. 4. Eliminate the need for analgesic administration.

2. Prevent dehydration and hypoxemia. NCLEX

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. Hold her breath. 3. Breathe rapidly. 4. Push with each contraction.

3. 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.) NCLEX

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 HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4. Call the HCP to the labor and delivery unit to perform a delivery.

3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP). NCLEX

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

3. Encourage an upright or side-lying maternal position. (cord compression) NCLEX

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 prep 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. Explain to the client why a cesarean delivery is necessary. NCLEX

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

3. Fetal heart rate pattern NCLEX

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 ampicillin 1 g as an intravenous piggyback every 6 hours.

3. Perform a vaginal examination every shift. (risk of infection) NCLEX

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Place the client in a high Fowler's position. 3. Continue the oxytocin (Pitocin) drip if infusing. 4. Administer oxygen, 8 to 10 L/minute, via face mask.

4. Administer oxygen, 8 to 10 L/minute, via face mask. (to optimize oxygenation) NCLEX

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

4. Complaints of severe abdominal pain (sign of uterine inversion or rupture) NCLEX

A 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. 2. Place the mother in a Trendelenburg position. 3. Administer oxygen to the client by face mask. 4. Document the findings and continue to monitor fetal patterns.

4. Document the findings and continue to monitor fetal patterns. (early decelerations are normal) NCLEX

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. NCLEX

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.

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. -left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation -↑ rate of the IV infusion will increase blood volume, which will increase the maternal BP and placental perfusion -↑ rate of oxygen will ↑ the oxygen levels in the maternal circulation and oxygen delivery to the fetus NCLEX

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4. Variable decelerations -occur if the umbilical cord becomes compressed, reducing blood flow -accelerations and variability are normal -early decelerations result from pressure on the fetal head during a contraction NCLEX

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the most appropriate nursing action? 1. Sit the client in a high Fowler's position. 2. Call the pharmacy for a tocolytic medication. 3. Get intravenous (IV) therapy equipment and solution from the storage area. 4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. NCLEX

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position B. Apply a fetal scalp electrode C. Insert an IV catheter D. Perform a vaginal exam

A. Assist the client into the left-lateral position (to increase perfusion - late decel = fetal hypoxia) ATI

A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3-5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Select all that apply) A. Encourage use of patterned breathing techniques B. Insert an indwelling urinary catheter C. Administer opioids analgesic medication D. Suggest application of cold E. Provide ice chips

A. Encourage use of patterned breathing techniques C. Administer opioids analgesic medication D. Suggest application of cold ATI

A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min that last for 25 seconds, and have beat-to-beat variability of 20/min. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (Select all that apply) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia

A. Moderate variability B. FHR accelerations D. Normal baseline FHR ATI

A nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factors of this condition? (Select all that apply) A. UTI B. Multifetal pregnancy C. Oligohydramnios D. Diabetes mellitus E. Uterine abnormalities

A. UTI B. Multifetal pregnancy D. Diabetes mellitus E. Uterine abnormalities (hydramnios is risk factor for preterm labor, not oligohydramnios) ATI

A client is admitted in active labor with ruptured membranes. She has contractions occurring every 2-3 minutes, lasting 45 seconds. After 6 hours of labor, her contractions are every 7-10 minutes, lasting 30 seconds. Which of the following orders would you anticipate from the physician? A. Morphine sulfate to be given stat B. IV fluids with an oxytocin (Pitocin) drip C. Nalbuphine (Nubain) to be administered every 2 hours D. Ampicillin 500 mg IVPB every 6 hours

B. IV fluids with an oxytocin (Pitocin) drip disc

A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin C. Nifedipine D. Betamethasone

D. Betamethasone ATI

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula at 2 L/min B. Apply a warm blanket C. Assist the client to a side-lying position D. Place an oxygen mask over the client's nose and mouth

D. Place an oxygen mask over the client's nose and mouth ATI

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. the nurse should know that a fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions

D. Relaxation between uterine contractions ATI

A nurse is caring for a client during an amnioinfusion. Which fetal heart rate (FHR) pattern would be an expected outcome of a successful amnioinfusion? a. A decrease in variable decelerations b. FHR rate of 100-110 beats per minute c. An increase in variable decelerations d. FHR rate of 160-180 beats per minute

a. A decrease in variable decelerations (variable decelerations should decrease following an amnioinfusion because the fluid buffers the cord from being compressed) text

A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? a. Fetal engagement b. Fetal lie c. Fetal attitude d. Fetal position

a. Fetal engagement (it is imperative that fetus is engaged at 0 station to prevent umbilical cord prolapse) ATI

A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. Hands and knees b. Lithotomy c. Trendelenburg d. Supine with a rolled towel under one hip

a. Hands and knees ATI

Regarding vaginal birth after cesarean (VBAC), which of the following statements is true? a. Misoprostol is contraindicated in women attempting a VBAC. b. After one successful VBAC, there remains an increased risk of neonatal and maternal complications in subsequent attempts. c. Research shows no significant correlation between maternal weight and successful VBAC. d. Healthcare costs are considerably higher for women who have a VBAC than for those who have a repeat cesarean birth.

a. Misoprostol is contraindicated in women attempting a VBAC. text

The nurse is preparing to assist with administration of amnioinfusion (AI). Which of the following nursing interventions is most appropriate? a. Obtain a solution of warmed, sterile normal saline. b. Monitor the fetal heart rate through intermittent electronic fetal monitoring (EFM). c. Ensure that fluids infused into the uterus are not expelled. d. Increase the rate of oxytocin infusion.

a. Obtain a solution of warmed, sterile normal saline. text

The nurse is present for a labor evaluation of a G2P1 at term by the family practice resident. He tells her she is 9 cm and will have her baby soon. She states "I'm really scared this one is going to come too fast. I had a lot of stitches with my first and I don't want that to happen again." What can the nurse do that will be most helpful to this client? a. Suggest pushing and birth in a side-lying position. b. Recommend an epidural to relieve the pain during the repair. c. Help her to accept whatever outcome occurs. d. Ask the resident to consider an episiotomy.

a. Suggest pushing and birth in a side-lying position. text

A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amnioinfusion. Which of the following conditions should the nurse plan to prepare an amnioinfusion? (select all that apply.) a. oligohydramnios b. hydramnios c. fetal cord compression d. hydration e. fetal immaturity

a. oligohydramnios c. fetal cord compression ATI

A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? a. turn the client on her left side b. palpate the client's uterus c. administer oxygen to the client d. increase the client's IV fluids

a. turn the client on her left side ATI

A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? a. Prolonged labor b. Reduced fetal oxygen supply c. Delayed cervical dilation d. Increased maternal stress

b. Reduced fetal oxygen supply (late deceleration causes: fetal hypoxia secondary to maternal hypotension, uterine hyperstimulation) ATI

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should then nurse identify as the priority? a. oxygen saturation b. temperature c. blood pressure d. urinary output

b. temperature (greatest risk following amniotomy is infection) ATI

A client with type 1 diabetes is admitted to the labor and birthing unit. What nursing action should the nurse perform first? a. Obtain prenatal record. b. Check urine for protein. c. Assess blood sugar level. d. Obtain a CBC.

c. Assess blood sugar level. text

A nurse is at the nurse's station looking at the central monitoring display for the labor and birth unit. Which tracing should be evaluated at the bedside first? a. Fetal heart rate 140-150 bpm, moderate variability, no accelerations or decelerations b. Fetal heart rate 120-125 bpm, minimal variability, no accelerations or decelerations c. Fetal heart rate 135 bpm, minimal variability, intermittent late decelerations d. Fetal heart rate 150-160 bpm, moderate variability, intermittent variable decelerations to 110 bpm

c. Fetal heart rate 135 bpm, minimal variability, intermittent late decelerations (tracing showing minimal variability accompanied by late decelerations is Category III and requires prompt evaluation and intervention) text

The fetal monitor has shown several late decelerations over the past 10 minutes. What does this pattern indicate? a. Umbilical cord compression b. Head compression c. Fetal hypoxia d. Maternal fever

c. Fetal hypoxia (A pattern of late decelerations indicates fetal hypoxia, caused primarily by uteroplacental insufficiency. Variable decelerations are caused by umbilical cord compression. Early decelerations are caused by head compression. Maternal fever may contribute to fetal tachycardia.) text

A nurse is preparing a prenatal client with a breech presentation for an external cephalic version (ECV). What condition must be met prior to this procedure? a. Mild labor contractions b. 34 weeks gestational age c. Reactive nonstress test d. Fetal breech must be engaged in the pelvis.

c. Reactive nonstress test text

A nurse is caring for a client in their latent phase of labor and is receiving oxytocin via continuous IV infusion. The client is having contractions every 2 min which last 100 to 110 seconds and the FHR is reassuring. What should the nurse do? a. decrease the infusion rate of the IV maintenance fluid b. administer oxygen via nonrebreather mask c. decrease the dose of oxytocin by half d. administer terbutaline 0.25 mg subcutaneously

c. decrease the dose of oxytocin by half (pt is experiencing uterine tachysystole) ATI

The nurse is performing a pelvic exam on a laboring client and discovers a loop of cord in the vagina. What is the initial nursing action? a. Administer oxygen at 5 L per minute. b. Call the primary healthcare provider or nurse-midwife. c. Place the client in a side-lying position. d. Apply upward pressure on the presenting part

d. Apply upward pressure on the presenting part text

The nurse has auscultated a fetal heart rate of 80. What should the nurse's initial action be? a. Position the client on her left side. b. Administer oxygen at 5 L per minute. c. Notify the primary healthcare provider or nurse-midwife. d. Check the maternal pulse.

d. Check the maternal pulse. (nurse should check the maternal pulse because 80 bpm could be maternal HR rather than the fetal HR) text

A nurse is assisting the primary healthcare provider with a forceps-assisted birth. What information from the nurse allows the primary healthcare provider to determine the appropriate time to apply traction? a. When a contraction ends b. The estimated midpoint between contractions c. The current dose of oxytocin d. When a contraction begins

d. When a contraction begins text

A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states "my water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. place the client in the Trendelenburg position. b. apply pressure to the presenting part with her fingers. c. administer oxygen at 10 L/min via a face mask. d. call for assistance.

d. call for assistance. ATI

hypertonic contractions

excessively frequent, uncoordinated, strong intensity, inadequate uterine relaxation

amnioinfusion indication

fetal cord compression, prolapsed umbilical cord

late deceleration causes

fetal hypoxia, uteroplacental insufficiency causing inadequate fetal oxygenation: -maternal hypotension -uterine hyperstimulation with oxytocin

late decelerations

slowing of FHR after contraction has started with return of FHR to baseline after contraction has ended

premature rupture of membranes (PROM)

spontaneous ROM before the onset of labor

variable decelerations

transitory, abrupt slowing of FHR <110/min, variable in duration, intensity, and timing in relation to uterine contraction

variable deceleration cause

umbilical cord compression (prolapsed cord, nuchal cord)

preterm labor

uterine contractions and cervical changes that occur between 20-37 weeks of gestation

signs of infection (3)

-fever -tachycardia (mother or fetus) -foul-smelling discharge