Chap 13 - 16
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?
Ambulate only with assistance from the nurse or caregiver.
A nurse is caring for a client in the first stage of labor. Which of the following interventions should the nurse implement to help alleviate pain?
Provide alternate cold and warm compresses
A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn? Select all that apply.
Sleep in a semi-Fowler's position. Limit consumption of food before bedtime. Avoid overeating.
Which cardinal movement of delivery is the nurse correct to document by station?
descent
tylenol and benydryl
if need to go home with contraction
A client in labor stares at a silver locket that her partner holds in front of her during a contraction. What type of distraction technique is the client using?
Focusing
A nurse is providing education to a client who is 8 weeks' pregnant. The client stated she does not like milk. What is a source of calcium that the nurse can recommend to the client?
leafy greens
The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with which?
the powers
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Meconium in the fluid
A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure?
To prevent supine hypotension syndrome
A nurse is assessing a pregnant woman in her last trimester. Which question would be most appropriate to use to gather information about weight gain and fluid retention?
"How swollen do your ankles appear before you go to bed?
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. (too far to retry)
Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication?
I have no pain now
A nurse is providing care to a couple who is planning to get pregnant within a short time and who need proactive nutritional strategies prior to conceiving. The nurse would most likely recommend which type of care?
Preconception visits
A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply:
Tea and gelatin Ginger ale and apple juice Cranberry juice and chicken broth
The nurse educates the vegetarian client about which nutritional need during pregnancy?
Taking a B12 supplement
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:
7.15 or less.
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
A woman in her first trimester shares with the nurse that she has been experiencing terrible nausea when she gets up in the morning. Which action should the nurse suggest? Select all that apply.
Eat some saltine crackers before rising in the morning. Suck on sour candies. Delay breakfast until 10 or 11 AM. Try eating a snack before bedtime
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?
Have the client pant and blow through the contraction.
A couple is writing out the birth plan for their labor and delivery. They desire an atmosphere with a dark, warm room and soft music playing. They opt for delayed cord clamping and an immediate warm bath after the infant is born. What type of birth does the nurse understand the parents are requesting?
The Leboyer method
The client may spend the latent phase of the first stage of labor at home unless which occurs?
The client experiences a rupture of membranes
Which assessment findings of the fetus during labor are reassuring? Select all that apply.
Variability between 18-20 bpm Fetal heart baseline of 130 bpm
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
assess for labor progression
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?
degree of thinning
A client at 28 weeks' gestation is asking for a laxative for constipation. What action would the nurse recommend?
eat fiber rich foods
At a routine prenatal visit, a client asks the nurse for information on the Bradley method of childbirth. Which of the following would the nurse identify as an active participant during childbirth using the Bradley method?
father
active management
give pictocin unless they refuse, shortened third stage (placenta)
Which nursing action is required before a client in labor receives an epidural?
giving a fluid bolus of 500 ml
The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?
longitudinal
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged."
13s The nutritional needs of an adolescent pregnant patient are unique because
Owing to typical food choices, an adolescent is often lacking calcium, iron, and folic acid in the diet
A patient is concerned about the mercury levels in fish and asks the nurse which fish are safe to eat. The best response is
Shrimp, canned tuna, pollack, and catfish (smaller fish have lower conc of mercury)
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?
complete cervical dilation and time of fetal birth
A nursing instructor is teaching about nonpharmacological techniques used for pain relief in labor. What are some techniques that the nurse would include in teaching? (Select all that apply.)
conscious relaxation consciously controlled breathing effleurage focusing imagery
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
inability to push
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?
it distracts the brain from the sensations of pain
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 coaching the mother during labor and tells her to breathe slowly from the chest at a rate of 6 to 12 breaths per minute. For what type of contractions would this method of breathing be best?
early contractions
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia
A pregnant woman at the clinic tells the nurse that her goal is to not take any medications during labor. What is the nurse's best response to this patient?
"The ultimate goal of childbirth is a healthy baby and healthy parents. Sometimes medication is necessary."
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?
+4
Which assessment findings indicate a distressed fetus? Select all that apply.
Absent accelerations Late deceleration patterns Persistent bradycardia
The nurse in a women's center is assisting the health care provider in obtaining the measurement of a pregnant client's pelvis. Which measurements are suggestive of the ability to have a vaginal delivery? Select all that apply.
An obstetric conjugate of 12 cm. A pubic arch angle of 90 degrees Minimal ischial spine protrusion into the midpelvis
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 pregnant client and her spouse come to the clinic to discuss options available for the labor and birth of their child. What should the nurse encourage clients to do in preparation for the birth of their child?
Have the couple write out a birth plan to better meet their needs during labor and delivery.
A nurse is conducting an informal teaching session for a group of pregnant women about childbirth education classes. Which information would the nurse most likely include as an outcome associated of these types of classes? Select all that apply.
Increased satisfaction Reduction in amount of reported pain Increased feelings of control
25s A nurse is discussing the benefits of childbirth education courses to a client who recently learned that she is pregnant. Which of the following are generally accepted as benefits of such classes? (Select all that apply.)
Increased satisfaction in the birth experience Decrease in the amount of pain reported in childbirth Decrease in risky behaviors, such as smoking, during pregnancy Increased feelings of control during childbirth Increased likelihood to breastfeed
Which is identified as the primary outcome for initiating comfort measures during the labor process?
Maintain the labor process
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?
Nothing. Normal time for stage three is 5 to 30 minutes.
A nurse suggests to a client planning to start a family that she and her partner should attend childbirth education classes. Which of the following are taught in childbirth classes? Select all that apply.
Nutritional needs in pregnancy Stress management Healthy relationships
A nurse is teaching a pregnant client how to perform tailor sitting. She cautions the client to put one leg in front of the other and to not put one ankle on top of another to avoid which of the following potential complications?
Occluding blood supply to the lower legs
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply.
Oxytocin Progesterone Prostaglandins
The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?
Pain originates from the cervix and lower uterine segment.
A client is in active labor. As one of the nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder," what would be appropriate for the nurse to do in order to achieve the goal of "no complications due to a full bladder"?
Palpate the area above the symphysis pubis every 2 hours.
A woman whose body mass index (BMI) is 32 has just learned that she is pregnant. Which of the following should the nurse advise her regarding her weight over the course of her entire pregnancy?
She should gain 11 to 20 lb
A patient in labor is transported to the OR for a cesarean section. The nurse places the patient in the:
Supine position with a wedge under the left hip
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
The cervix is softening
The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data?
The client has saturated three sanitary napkins in the past 4 hours.
The nurse is caring for four clients within the labor and delivery unit. Which client does the nurse anticipate will be sent home?
The primigravid who has a thinning cervix and a dilation of 3 cm
Which assessment finding is most important as labor progresses?
The uterus relaxes completely between contractions.
The pain of labor is influenced by many factors. What is one of these factors?
The woman is prepared for labor and birth.
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?
This may prolong labor and increase complications.
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes?
a positive nitrazine test
The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?
acme
When teaching a client about nutrition during pregnancy, the nurse should include which long-term outcomes in the plan of care? Select all that apply.
developing healthy patterns for a lifetime identifying foods to build iron stores incorporating foods to build bone mass designing a diet consistent with cultural factors
Nausea and vomiting are common reports during pregnancy. What nutritional action can be used to lessen nausea and vomiting?
limiting intake of heavy, greasy foods
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?
maternal hypotension and fetal bradycardia
The nurse is admitting a client who has just arrived stating she is in labor. Which fetal assessments will the nurse prioritize on the initial vaginal examination? (Select all that apply.)
presentation position attitude
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
A nurse is caring for a female client in labor who has chosen hydrotherapy as her pain management for labor. As the nurse prepares the client for this treatment, which procedure is recommended as the most appropriate consideration?
the client should be in active labor
A birth in which the lights are kept low, noise is kept to a minimum, and the newborn is placed into a warm bath immediately following delivery is called
the leboyer method
a woman's perception of pain can differ according to all of the following except:
the presentation, lie, and attitude of the fetus.
A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:
transition phase of the first stage of labor.
the client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?
use a birthing ball and find a position of comfort
When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?
"Tell me how you handled labor pain in your past deliveries."
Mrs. M is now 20 weeks' gestation. At conception her weight was considered "normal." Approximately how much weight should she have gained by this time?
11 to 12 pounds
A G2 P1 client, at 37 weeks' gestation, arrives to the unit and annouces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in?
Inform the RN that your client may have ruptured membranes
During pregnancy most nutritional needs can be consumed in adequate amounts through the diet. What nutrient is the exception to this statement?
iron
Which nursing action has a negative effect on fetal descent?
narcotics
fourth stage
recovery
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?e
third
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?
continue with the admission assessment
The nurse is educating a pregnant woman and her partner to trace a pattern on her abdomen with her fingertips as a distraction method during contractions. What type of distraction method is this considered?
effleurage
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate
A client has moved into the active phase of labor and is now at 6 cm dilated and +1 station. The nurse is prepared to monitor the contraction pattern how often?
every 30 min
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 is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which?
fetus is in the true pelvis and engaged
The nurse is discussing nutritional supplementation with a 27-year-old pregnant client. Which element would the nurse encourage as essential in preventing neural tube defects?
folic acid
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?
increased white blood cell count (stress of labor)
After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROA position. To best auscultate the fetal heart tones, the Doppler is placed:
Below the umbilicus on the right side
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?
Continue to monitor the client and the FHR
After teaching a group of students about Grantley Dick-Read and his view of childbirth, which of the following if identified by the students as an activity advocated by Dick-Read indicates that the teaching was successful?
Controlled breathing
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?
Engagement
The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus?
Facing the right anterior pelvic quadrant
A nurse is working to increase participation in childbirth education classes for pregnant women who are receiving care at the clinic. To achieve this goal, which area would the nurse need to focus on as a common reason why some women shy away from attending these classses?
Fear that participation means commitment to a medication-free birth
A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.
A nurse is educating a group of nursing students about the etiology of labor. Which of the following should the nurse explain as the hormone produced by the posterior pituitary?
Oxytocin
A pregnant client mentions to the nurse that a friend has given her a variety of herbs to use during her upcoming labor to help manage pain. Specifically, she gave her chamomile tea, raspberry leaf tea, skullcap, catnip, jasmine, lavender, and black cohosh. Which of these should the nurse encourage the client not to take because of the risk of acute toxic effects such as cerebrovascular accident?
black cohosh
pain meds in labor
can give twice, an hour apart, works less the second time and now youre feeling Side effects too
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?
cervical dilation
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?
change position
A nurse is providing education to a client who is 8 weeks' pregnant. The client stated she does not like milk. What is a source of calcium that the nurse can recommend to the client?
dark, leafy green vegetables
A nurse assesses a primigravida client in the eighth week of gestation. The client reports nausea and vomiting in the mornings. The client tells the nurse, "I'm not able to keep liquids down and I'm eating like a bird." The client also expresses concerns about hormonal changes and how the pregnancy will affect her physical appearance. Which client problem should the nurse assess first?
deficient fluid volume
A nursing student correctly identifies the childbirth preparation method that focuses on the premise that fear leads to tension, which leads to pain, is known as which of the following?
dick-read method (The method based on the premise that fear leads to tension and tension leads to pain is the Dick-Read Method. The woman can achieve lack of fear through education about childbirth and relaxation and reduced pain by focusing on abdominal breathing during contractions.)
Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would you expect?
does not hyperventilate
When a nurse is providing sibling education classes to children, what information can the nurse include that will address safety for the pregnant mother?
dont leave toys on the floor
A pregnant client states, "I am only 6 weeks pregnant, but the morning sickness is awful. When is it going to stop?" What is the best response by the nurse?
"Usually after 12 weeks, when the placenta starts managing the production of progesterone, morning sickness ends."
The nurse is teaching an active pregnant woman about nutritional needs to maintain a healthy pregnancy. The nurse determines that the teaching was successful when the woman states that she need about how many calories per day?
2500 calories per day
You are discussing weight gain with a group of pregnant women at the clinic. One woman is very thin and her prepregnancy weight falls below the normal weight range for her height. What is her recommended weight gain during her pregnancy?
28 to 40 pounds
You are discussing weight gain with a group of pregnant women at the clinic. One woman is very thin and her prepregnancy weight falls below the normal weight range for her height. What is her recommended weight gain during her pregnancy?
28-40 lbs
Which of the following is true regarding problems that commonly affect nutritional health in pregnancy?
50% of women report pyrosis at some point in pregnancy.
What is the recommended amount of protein (grams/day) in pregnancy?
71 g/d
A nurse is attending a seminar on the psychology and physiology of the pain of labor. Which action would indicate that the nurse has understood the information and has integrated this knowledge in the plan of care for a woman in labor? Select all that apply.
Asks the client for her preferences in managing pain Provides non-pharmacological measures Assists in measures to enhance client's endorphin release
A nurse recommends to a couple, who are soon to be parents that they attend early prenatal classes. Which of the following topics would be covered in an early prenatal class?
Physical and emotional changes of pregnancy
The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage?
cervix
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
cervix is fully dilated
6s The nurse is teaching about an iron supplement that client is going to take every day. The nurse teaches the client to take the iron supplement with which type of fluid?
citrus juice
A multigravida client admitted in active labor has progressed well and the client ane fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?
inspect the perineum
Nutritional requirements generally go up during pregnancy. Which nutritional requirement proportionally increases the most during pregnancy?
iron
A pregnant client has just received general anesthesia for the birth of her neonate. The client aspirates. The nurse anticipates the primary care provider will administer which medication?
isoproterenol (If aspiration of vomitus should occur following general anesthesia administration, prompt attention is essential. The anesthesiologist suctions the woman's trachea to remove as much foreign material as possible. The woman is intubated, if she was not previously, and given 100% oxygen. IV isoproterenol to reduce bronchospasm and a corticosteroid to reduce inflammation may be given.)
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 nursing instructor is teaching about the importance of childbirth classes for pregnant women. Which of the following statements made by a student indicates a need for further instruction?
"Childbirth classes give information only on how to prepare for childbirth."
nursing instructor is teaching about the importance of childbirth classes for pregnant women. Which of the following statements made by a student indicates a need for further instruction?
"Childbirth classes give information only on how to prepare for childbirth."
The nurse is conducting a teaching session for breastfeeding mothers. Which statement by a mother requires further clarification by the nurse?
"I am glad I can have my two cups of coffee in the morning again."
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:
"I may end up with a severe headache from the spinal anesthesia."
The nurse is completing the teaching for a newly pregnant client with a BMI of 23. Which statement by the client indicates an understanding of weight gain during this pregnancy?
"I need to gain 25 to 35 pounds (11 to 16 kg) during this pregnancy."
A woman has informed the nurse that she plans to have a freebirth. Which statement indicates that the woman understands what freebirth entails?
"I plan on giving birth at home without anyone around except my husband and my children."
A nurse is providing prenatal education about microorganisms to avoid during pregnancy. Which of the following statements from the nurse is correct?
"Pregnant women should avoid unpasteurized dairy products and undercooked meats."
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
-2 station.
A patient of normal weight and new to the obstetric clinic asks the nurse how much weight to gain during pregnancy. What is the best response the nurse can give?
10 lbs over the first 20 weeks; 1 lb per week after that
a nurse is instructing a pregnant client on the benefits of squatting to stretch the perineal muscles. How many minutes a day should the client perform squatting?
15
A pregnant client of normal weight is concerned about excessive weight gain during her pregnancy. She states, "I don't want to get fat!" The nurse should inform her that she can expect to gain how much weight during her pregnancy?
25 to 30 pounds
The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?
6.5
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
The nurse notices that a client in labor who is receiving an epidural has suddenly become drowsy. When the nurse asks her how she is doing, the client complains of a metallic taste in her mouth and blurred vision. Her speech is slurred. The nurse recognizes this as a serious complication related to the epidural. Which intervention would the nurse implement as a priority in this situation? Select all that apply.
Administer oxygen to the client Administer an anticonvulsant to the client Prepare for prompt birth of the fetus (In rare instances, the anesthetic, instead of settling into the epidural space, enters the woman's blood circulation. Drowsiness, a metallic taste on the tongue, slurred speech, blurred vision, unconsciousness, and seizure which may lead to cardiac arrest are alerts this has happened and, again, is an emergency situation. The woman needs oxygen and an anticonvulsant such as diazepam (Valium) or thiopental (Pentothal) IV, followed by prompt birth of the fetus to protect her and her fetus' health. )
A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management?
Administration of 500 mL of IV Ringer's lactate (The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This risk can be reduced by being certain a woman is well hydrated with 500 to 1000 mL of IV fluid, such as Ringer's lactate, before the anesthetic is administered. Ringer's lactate is preferable to a glucose solution, because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. )
A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?
Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.
The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper?
blue (alkaline)
The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful?
comfort measures
A nurse is reading a journal article about childbirth and the role of doulas in childbirth. The nurse demonstrates understanding of the article when the nurse identifies which activity as a function of a doula?
Caring for the mother's emotional needs
A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?
Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask.
A primagravida has an office appointment in her 39th week of pregnancy. Which assessment data is most definitive of the onset of labor?
Cervical ripening is noted on examination.
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
Ask the client to describe the intensity of her pain on a scale of 0 to 10.
The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?
Assess fetal heart rate.
When developing a plan of care, the nurse needs to make which assessments for a pregnant client with a BMI of 18.3? Select all that apply.
assess for maternal fatigue assess for poor fetal growth assess for preterm labor
During which time is the nurse correct to document the end of the third stage of labor?
at the time of placental delivery
At 32 weeks' gestation a client with a BMI of 23 has gained 24 lb (11 kg). What is the nurse's recommendation for weight gain for the remainder of this pregnancy?
Continue to gain approximately 1 lb (.45 kg) per week during this pregnancy.
A nurse is teaching a group of pregnant woman about pain control during labor and birth. As part of the teaching plan, the nurse reviews the gating theory of pain control. Which technique would the nurse describe as assisting in halting gating mechanisms to alter pain perception? Select all that apply.
Cutaneous stimulation Distraction Reduction of anxiety
The couple preparing for the upcoming birth of their child is researching information about alternative birthing centers (ABCs). The couple demonstrate understanding of this birth setting when they identify which information as a disadvantage? Select all that apply.
Extended high-risk care is not immediately available. A woman may be fatigued after birth because of a brief health care setting stay. A woman must independently monitor her postpartal status because of a brief stay.
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions?
begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity
A patient has a BMI of 23, and her singleton pregnancy is uncomplicated. Which information would the nures include when counseling this patient about her weight? Select all that apply.
It is recommended to gain 25 to 35 lbs. Weight gain is considered excessive if it exceeds 3 kg (6.6 lbs) a month. It it important to plan to gain approximately 1 lb a month during the first trimester.
First stage
Labor thru birth (latent, active, transition)
A client has had a normal labor progession after the spontaneous rupture of clear fluid at home. As the client continues to show no signs of complications which actions should the nurse prioritize to prepare for the birth? Select all that apply.
Move the newborn warmer to the birth area and turn it on. Check the functionality of the oxygen source and equipment. Document events as they are happening.
Which nursing suggestions are options for the client experiencing intense pain in the active phase of labor? Select all that apply.
Patterned breathing Hypnosis Pain medication Massage Acupressure (effleurage is only used in early phase)
how to relieve spinal headache (from spinal tap, headache bad when up and relieved when laying down)
blood patch or caffeine
The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the client's legs has returned, but she cannot lift her knees, and she has not been out of the bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time?
Risk for Injury
During stage 3 of labor, you note a gush of blood and that the uterus changes shape from an oval shape to a globular shape. This indicates what?
Signs of placental separation
A pregnant woman asks the nurse about abdominal and perineal exercises that she can do to make her muscles stronger. Which type of exercise would the nurse encourage the pregnant woman to practice approximately 15 minutes per day to stretch the perineal muscles and make them more supple for birthing?
Tailor sitting
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.
When developing a labor plan with the client, which outcome is the priority?
The client will direct her pain management techniques.
While monitoring the EFM tracing the nurse notes decelerations with each contraction. The nurse knows that for a deceleration to be classified as early it has to meet three criteria. What is one of these criteria?
The nadir of the deceleration coincides with the acme of the contraction. (Three criteria classify the deceleration as early: (1) the FHR begins to slow as the contraction starts; (2) the lowest point of the deceleration, the nadir, coincides with the acme (highest point) of the contraction; and (3) the deceleration ends by the end of the contraction.)
Which of the following is not a physiologic basis for painful contractions during labor?
Uterine and cervical blood vessels dilate, increasing blood flow and causing hypoxia in the muscle fibers. (they constrict)
A nurse is working to develop programs that address women who are at high risk for inadequate nutrition in pregnancy. The nurse would target these programs to which women? Select all that apply.
Women who are pregnant with twins Women over age 40 Adolescents Women who are lactose intolerant Women who smoke or use recreational drugs
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
A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours?
You are still 2 cm dilated, but the cervix is thinning out nicely."
When counseling a Japanese American about nutrition and diet in pregnancy, it would be important to include
a list of foods that contain calcium
A client in labor has received a spinal epidural block. Which nursing intervention should the nurse prioritize after assessing maternal hypotension and changes in the fetal heart rate (FHR)?
administer supplemental O2
At which time is it most important to monitor for umbilical cord prolapse?
after rupture of membranes
When developing a plan of care, the nurse needs to make which assessments for a pregnant client with a BMI of 18.3? Select all that apply
assess for maternal fatigue assess for poor fetal growth assess for preterm labor
A nurse observes a woman in labor and her spouse as they practice breathing exercises to manage the client's pain. Before each contraction, she takes a deep, cleansing breath and then breathes at a controlled pace. During each contraction, she gradually shifts from slow, deep breaths to shallow, rapid ones and then back to slow, deep ones. Her spouse coaches her and performs effleurage on her abdomen. The nurse recognizes that this couple is using which method of pain management?
lamaze (A cleansing breath before each contraction, controlled breathing as described, and effleurage are all hallmarks of the Lamaze method. The Bradley method is characterized by abdominal breathing, walking, and using an internal focal point as a disassociation technique during labor. The psychosexual method includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to "flow with" rather than struggle against contractions. In the Dick-Read method, a woman achieves lack of fear through education about childbirth; she achieves reduced pain by focusing on abdominal breathing during contractions. Although all of the methods involve breathing, the specific approach outlined above corresponds with Lamaze.)
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:
latent phase of the first stage
The nurse is explaining childbirth education that follows the philosophy of the Lamaze Institute. Which information would the nurse include as an objective for the father?
learning basic comfort measures that help the woman in labor
he nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?
lie (The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?
naloxone
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?
practicing effleurage
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?
radiates from back to front
A nurse is caring for a client in the first trimester of her second pregnancy. Which of the following education classes would be most appropriate for the nurse to suggest?
refresher course
The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time?
reposition the client on either side
A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?
respiratory depression
Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?
significant head molding
A young woman comes to the clinic and informs the nurse that she and her husband are thinking about having a baby. She tells the nurse that she has read about the importance of increasing folic acid before conceiving. Which foods should the nurse tell the patient to consume to increase her level of folic acid? (Select all that apply.)
spinach collard greens kale turnip greens
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?
Take no extra measures; prepare for a standard labor.
Which action is a priority when caring for a woman during the fourth stage of labor?
assessing uterine fundus
A client with hyperemesis gravidarium is started on TPN. What parameter does the nurse need to assess at least twice a day?
blood glucose
COAT
color, odor, amount, time
During the initial prenatal visit, the nurse performs what assessment to guide teaching about nutrition during pregnancy?
prepregnancy BMI
Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?
rupture of amniotic membranes
The recommended weight gain during the first trimester for a woman who was in the normal weight range prepregnancy is 2 to 4 pounds. After the first trimester, what is the recommended weekly weight gain for a woman who was considered normal weight prepregnancy?
1 lb
A woman entering her third trimester of pregnancy asks the nurse how much weight she should gain during this trimester. What is the nurse's best answer?
1 lb/week (A woman of normal prepregnant weight should gain about 10 lbs by 20 weeks and about 1 lb/week for the remaining 20 weeks, for a total of 25 to 30 lbs)
A nurse is reviewing the medical records of several women who come to the prenatal clinic for care. The nurse plans to increase the number of teaching sessions on nutrition for the women at risk for poor nutritional status. Which woman would the nurse most likely identify as needing the additional sessions. Select all that apply.
A woman who is 42-years of age A woman whose prepartum weight was less 85% of ideal weight. A woman who shows a weight gain of 2 or more pounds per week.
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?
Clear to straw-colored fluid
A client in her second trimester of pregnancy complains to the nurse of heartburn. Which of the following should the nurse suggest to the client as a preventative measure?
Have small frequent meals
A nurse observes a woman in labor and her spouse as they practice breathing exercises to manage the client's pain. Before each contraction, she takes a deep, cleansing breath and then breathes at a controlled pace. During each contraction, she gradually shifts from slow, deep breaths to shallow, rapid ones and then back to slow, deep ones. Her spouse coaches her and performs effleurage on her abdomen. The nurse recognizes that this couple is using which method of pain management?
Lamaze
19s A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?
ROA (The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.)
A client in the first trimester reports having nausea and vomiting, especially in the morning. Which instruction would be most appropriate to help prevent or reduce the client's compliant?
dry crackers or toast before rising
The nurse is describing pregnancy danger signs to a pregnant woman who is in her first trimester. Which danger sign might occur at this point in her pregnancy?
excessive vomiting
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
fetal lie
A young woman in her first trimester confesses to the nurse when questioned that she is probably not consuming enough calories. The nurse should explain to this client that deficient nutrition can hinder the baby's growth, which at this point in her pregnancy is primarily via an increase in the number of cells formed. This type of growth is known as which of the following?
hyperplasia
12s A client in her second trimester of pregnancy complains to the nurse of heartburn. Which of the following should the nurse suggest to the client as a preventative measure?
small frequent meals
A client in her second trimester of pregnancy complains to the nurse of heartburn. Which of the following should the nurse suggest to the client as a preventative measure?
small frequent meals
rse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?
sudden gush of dark blood from the vagina
Vitamin B12 deficiency is most likely to be found in which patient?
vegan
During the examination of a pregnant client, the nurse observes pale mucous membranes and cracks at the corners of the mouth. The nurse recognizes that these findings suggest what type of deficiency?
vitamin A
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?
wash hands
