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A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part?

At the level of the ischial spines

The nurse is teaching participants in a prenatal class regarding breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which response is most appropriate

"Breastfed infants have fewer infections."

After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond?

"I'll get you some warm blankets to help make the chill go away.

The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter?

"I'm not exactly sure how an epidural works.

A pregnant client uses a computer while sitting almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend?

"Try to walk around every few hours during the workday."

The nurse is reviewing the documented results of a lecithin/sphingomyelin (L/S) ratio. Which finding is indicative of fetal lung maturity?

2:1

At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question?

Accompanied by progressive cervical dilation

Which physiologic alteration does the nurse expect in a client's hematologic system during the second trimester of pregnancy?

An increase in blood volume

What should a nurse include in nutritional planning for a newly pregnant woman of average height who weighs 145 lb (65.8 kg)?

An increase of 300 calories per day

After a client gives birth, which physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

Appearance of a sudden gush of blood

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do?

Apply cold packs and a snugly fitting bra

What should a nurse teach a nonbreastfeeding mother to help relieve the discomfort of engorgement?

Apply cold packs to the breasts frequently

A client tells the nurse that the first day of her last menstrual period was July 22. What is the estimated date of birth (EDB)?

April 29

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?

Cervical dilation

A client at 40 weeks' gestation is admitted to the birthing unit, and an amniotomy is performed to facilitate labor. Once the nurse determines that the umbilical cord has not prolapsed, what is her next action?

Correct1 Assessing the fetal heart rate

While experiencing contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse's priority intervention be at this time?

Correct2 Inspect the client's perineum for bulging.

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with what?

Doppler ultrasound at 10 to 12 weeks

Which instruction is most important for the nurse to include when teaching a client about a contraction stress test (CST)?

Empty the bladder before the test

During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent?

Fetal Hypoxia

Because of the increased discomfort level during the transition phase of labor, nursing care should be directed toward what?

Helping the client maintain control

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear?

Low-heeled shoes

A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. Which breathing pattern should the nurse instruct the patient to adopt?

Pant and then exhale through the mouth with pursed lips

Which finding indicates the development of a complication resulting from bilateral cephalohematomas?

Skin color

The nurse is caring for a client in the first stage of labor. Which position is the least desirable for the client if she is experiencing lower back pain?

Supine

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she feels as though she is going to vomit. Which phase of the first stage of labor does the nurse suspect the client has entered?

Transition

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention

Turn her onto her left side

Which position does the nurse teach the client to avoid when she experiences back pain during labor?

supine

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?

cupped hands

On a 6-week postpartum visit a new mother tells the nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach the mother that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for what?

Correct2 Vitamin C and iron

A new mother wishes to breast-feed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond?

"You'll need greater amounts of the same foods you've been eating and more fluids."

A client is admitted to the birthing unit in active labor. An amniotomy is performed by the healthcare provider. Which physiologic alteration does the nurse expect to occur after the procedure?

Progressive dilation and effacement

A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed?

Progressive dilation and effacement

During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response?

"If you add 340 calories a day to your regular diet, you won't become overweight."

The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day?

Pinkish brown

A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take?

Discontinuing the test because the pattern is within the normal range

A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention is the priority for the nurse at this time?

Documenting the amount of bleeding in the infant's chart

While conducting prenatal teaching, the nurse should explain to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase?

Increased production of estrogen

At 40 weeks' gestation a client is admitted to the birthing unit in early labor. She asks the nurse, "Why do you want me to lie on my side?" Which response by the nurse explains the primary purpose of the side-lying position during labor?

"It enhances blood flow to the uterus and makes contractions easier.

A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show present. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond?

"It's all right for you to walk as long as you feel comfortable and your membranes are intact.

A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and dilated 3 cm. The fetal head is at +1 station. In which area of the client's pelvis is the fetal occiput?

Below the ischial spines

The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?

Enlarging area of caput with each contraction

A nurse performs Leopold maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is what?

LOA The fetus is in a left occiput anterior (LOA) position because the buttock (firm mass) is in the fundus, the back is on the left, the small parts are on the right, and the head is flexed, indicating an anterior occiput. The right occiput anterior (ROA) position is indicated by the presence of the back on the right side and the cephalic prominence on the left side; the occiput is anterior. The left mentum posterior (LMP) position is marked by cephalic prominence. The back is on the same side, indicating an extended head and chin presentation. In the right mentum posterior (RMP) position, the back and cephalic prominence are situated on the same side (right), indicating an extended head and chin presentation.

A client at 42 weeks' gestation has a reactive nonstress test. The nurse determines that the client understands what she was taught about the results when she is overheard telling her husband that the test was what?

Normal because of an increase in fetal heart rate (FHR) with fetal movement

The nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located

One or two fingerbreadths below the umbilicus

Which information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?

Physical and emotional changes resulting from pregnancy

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?

Provide the client with comfort measures used for women in labor

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately?

Reposition the client from supine to left lateral

Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration.

Repositioning the client from side to side