Exam 1
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 would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression.
The nurse is caring for a client with a G=5, T=0, P=3, A=1, L=3 obstetric history. The nurse is most correct to state which interpretation?
the client has difficulty reaching full term
Which description is best when documenting an accurate client contraction?
the client's contractions are 5 minutes apart and last 45 seconds
A nurse urges a pregnant client at the first prenatal office visit to begin taking iron supplements immediately. What is the rationale for this intervention?
to avoid anemia
A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?
Respiratory depression, hypotension, absent tendon reflexes
The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?
late decelerations
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant
A client comes to the emergency department reporting strong contractions that have lasted for the past 2 hours. Which assessment will indicate to the nurse that the client is in true labor?
progressive cervical dilation (dilatation) and effacement
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?
turn off oxytocin
A woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse suspect?
uterine rupture
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?
vaginal examination
The nurse is measuring the fundal height of a woman who is at 28 weeks' gestation. Which measurement would the nurse expect?
28 cm
If constipation is a problem for a woman during pregnancy, which measure would be best to recommend?
increased fiber intake
A nurse at the health care facility assesses a client at 20 weeks' gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?
at the level of the umbilicus
Which condition is the most common cause of anemia in pregnancy?
iron-deficiency anemia
What would be the physiologic basis for a placenta previa?
low placental implantation
A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement?
provide emotional and physical support
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?
push with contractions and rest between them
A pregnant client is excited that she is beginning to feel her baby move within her. The nurse explains that these first fetal movements are known as:
quickening
Which feature would alert the nurse that the client is in the transition phase of labor?
beginning urge to bear down
A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement?
change maternal position to an upright or side lying position
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
change the client's position
A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal?
clear
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?
duration
A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?
early decelerations
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?
assessing fetal heart tones by use of an external monitor
A primapara woman, 30 weeks' gestation, has no family support and frequently calls the health care provider's office with questions. Which report by the woman would alert the nurse that she may be having a complication related to the pregnancy and needs to come to the clinic today for further assessment?
feeling of achy, cramping in vaginal area accompanied by bleeding that has saturated 1 pad/hour
In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion?
fetal heart rate accelerations
A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?
gestational trophoblastic disease
A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?
"knife-like" abdominal pain with vaginal bleeding
Which method does the nurse use to determine fetal presentation, position and attitude?
Utilize Leopold maneuvers
You care for a woman in a prenatal clinic who thinks she might be pregnant. Which of the following assessments is a probable sign of pregnancy?
a positive pregnancy test
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
assess vital signs
A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?
Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.
Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?
abdominal pain, vaginal bleeding, and a positive pregnancy test
A woman whose fetus is in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain?
applying counterpressure to the back
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?
assess fetal heart sounds
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:
assess the rate of flow of the oxytocin infusion
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:
baseline FHR
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?
decrease in circulation and perfusion to the fetus
A woman in her third trimester is suffering from heartburn. What should the nurse advise her to do?
eat small meals frequently rather than large meals
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?
fetal heart rate of 80 beats/minute
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
fetal lie
The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?
maternal tachycardia and falling blood pressure
A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client is not in labor. Which nursing intervention should the nurse perform?
monitor the amount fo vaginal blood loss
A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?
occiput posterior position
The nurse is admitting a client with a suspected diagnosis of abruptio placentae. Which assessment data would require the nurse to notify the healthcare provider immediately? Select all that apply.
overt vaginal bleeding a rigid abdomen decreased blood pressure increased heart rate
The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby?
1 cm below the ischial spine
A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?
McRoberts maneuver
A client is 20' weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client?
The client has pink vaginal discharge and pelvic pressure.
A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which condition should the nurse monitor the fetus?
fetal hypoxia
A woman asks the nurse if she can take an over-the-counter vitamin during pregnancy rather than her prescription prenatal vitamin. A chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition is:
folic acid
When evaluating a pregnant client's fundal height, the nurse should measure in which way?
from the symphysis pubis notch to the highest level of the fundus
A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?
gestational hypertension
A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination, there is an elevated human chorionic gonadotropin (hCG) level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition?
gestational trophoblastic disease
A pregnant client has come to the labor and birth suite in labor. The nurse reviews the client's medical record and determines that a vaginal birth is favorable based on which finding related to the client's pelvic shape?
gynecoid
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client?
increasing fluid intake
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:
lightening
A nursing student correctly identifies the most desirable position to promote an easy birth as which position?
occiput anterior
During their experience in L & D, a group of nursing students are observing a woman who is having uncoordinated contractions where the monitor shows some contractions close together, followed by a long period without any contractions. The nurse asks the students, "Which medication may help to stimulate a more effective, consistent pattern of contractions?" Which medication would be considered the best answer?
oxytocin
A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating?
preterm labor
A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?
tocolytic therapy
The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply.
IV hydration maternal position change oxygen administration
What actions does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply.
assigning the Apgar scores drying the newborn initiating skin to skin care taking newborn vital signs
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?
palpate the fundus and check fetal heart rate
A client in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history, what should the nurse suspect?
placenta previa
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
Which two tests are generally performed on urine at a prenatal visit?
protein and glucose
Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?
rupture of amniotic membranes
A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?
umbilical cord prolapse
The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?
uteroplacental insufficiency
