Exam 2 review questions

A pt who is at 7mths gestation presents to the ED w/ reports of a large gush and continuous leaking of fluid form her vagina. She does have some slight pelvic pressure but denies any contractions. this pt is showing clinical signs of which of the following?

PROM

Four hours after delivery a mother suddenly complains of not being able to breathe and is gasping for breath. The nurse administers oxygen and calls for help. Which type of oxygen delivery device would be most appropriate for the nurse to utilize?

nonrebreather mask

the nurse is caring for a laboring mother who is experiencing a protracted active phase of labor. The nurse prepares for which two interventions to assist the mother through this phase of labor.

oxytocin and amniotomy

A client is experiencing dysfunctional labor that is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this client?

oxytocin therapy.

After learning that her fetus is in the LST position, the client asks the nurse what this means. Which structure will the nurse point out is presenting first.

buttocks

The mother has suffered an amniotic fluid embolism. She has a sudden onset of tachycardia, weak thready pulses, is pale and diaphoretic. The nurse recognizes these symptoms as:

cardiogenic shock

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?

cervical dilation of 2 cm or more.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse take in this situation.

continue to monitor the fetal heart rate because this pattern is benign.

A RN is reading a journal article about cervical ripening agents, based on the understanding that certain pharmaceuticals can be used to attain cervical ripening in women who need assistance in this area. They have also often continued into labor without further agents to stimulate uterine contractions. Which agent would the nurse anticipate reading about as an FDA-approved agent for cervical ripening

dinoprostone

a pregnant client receiving intravenous oxytocin for 1 hr has contractions lasting 80 sec. What should the nurse do first for this client

discontinue the oxytocin infusion

It is necessary for the mother to have a forceps delivery. To reduce complications from this procedure, the nurse should:

empty the mother's bladder

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs?

every 30 minutes

At 31 wks gestation, a 37 y/o woman wH/O preterm birth reports cramps, vaginal pain, and low, dull backache accompanid by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3-4cm. Which interactions should the nurse prepare to assist with?

hospitalization, tocolytic, and corticosteroids.

massage is an effective nonpharmacologic technique that can help to decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism?

increasing the release of endorphins

The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this as which phase.

increment

A nurse is caring for a client at 30 wks gestation who had preterm premature rupture of membranes 25 hrs ago. The client has a temperature of 102 F and a foul smelling odor from the vagina. Which medication order should the nurse question?

magnesium sulfate 2gm IV/hr

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

a nurse is assessing a woman after birth and notes a second-degree laceration. the nurse interprets this as indicating that the tear extends through which area?

muscles of perineal body.

When a woman in labor has reached 8cm dilation, the nurse notices the fetal heart rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. the nurse's first action would be to:

place her in a knee-chest position.

The nurse is caring for a client at 39 wks gestation who is noted to be a 0 station. the nurse is correct to document which?

the fetus is in the true pelvis and engaged.

A G2P1is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the VS obtained 15 min ago. the RN should investigate further for additional signs or symptoms of which complication?

uterine rupture

the nurse assess the client and tells her the baby is at +1 station. Which is the best response by the nrse when asked by the client what this means concerning the location of the baby.

- 1 cm below the ischial spine

A multiparous woman at 39 weeks' gestation arrives at the L+D unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix and 3 cm dilation. Which nursing action is the best?

Have the client ambulate in hall and recheck

A nursing student is learning about fetal presentation. the nursing instructor realizes a need for further instruction when the student makes which of the following statements?

Transverse lie is the same as when the fetal buttocks present to the birth canal.

the nurse is assisting with a G2P1, 24 Y/O client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

Use McRoberts maneuver

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?

administer 500 ml of IV LR

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

Acceleration of at least 15 bpm for 15 sec

A client in labor has requested the administration of opioids to reduce pain. At 2cm cervical dilation, 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.

Mrs. Carter is admitted to the l+ D unit. The lab results of her cervical culture for group B streptococcal were positive. What priority intervention will be initiated?

Ampicillin or cefazolin intravenous is given before delivery.

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority?

Blood pressure.

A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth?

Brachial plexus assessment

in providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

Knee-chest

The nurse is preparing a client in labor to receive a pudendal block with lidocaine. the nurse would place the client in which position for administration?

Lithotomy

A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hrs w/ no further descent, the provider D(x) "arrest of labor" the woman asks, "why is this happening?" which response is the best answer to this question?

More than likely, you have cephalopelvic disproportion where baby's head cannot make it through the canal.

The nurse is caring for a woman at 32 wks gestation who expresses deep concern because her previous pregnancy ended in a stillbirth. the nurse would encourage the mother to have what screening test?

Nonstress test (NST)

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate?

Providing a comfortable environment with dim lighting.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?

macrosomia

The nurse is teaching a pregnant client the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor?

-The fetal head bends forward onto the chest.

A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phased based on which assessment findings? SATA -cervical effacement of 90% -strong desire to push -cervical dilation of 6cm -contractions every 1-2 min -contractions lasting up to 60seconds.

-cervical dilation of 6cm -contractions lasting up to 1 min

Touch and massage can be helpful during labor. Which touch and massage methods are used in labor? SELECT ALL THAT APPLY -patterned breathing -water therapy -counterpressure -effleurage

-counterpressure effleurage

The laboring mother is becoming very tired because she is experiencing tachysystole. The nurse can use which interventions to assist this mother? SATA -Ambulation -Warm bath -opioid medication -sleeping medication

-warm bath -opioid medication -sleeping medication

the nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 mL urine output in 2 hrs.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is

5

A nurse working w/ a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10hr ago. the report indicates an absence of the protein, which the nurse knows indicates:

Birth is unlikely within the 2 next weeks

Which psychosocial state is anticipated when the client enters the active phase of labor?

The client will become more quiet and introverted.

the nurse notes the fetal heart rate has slowed in a woman in labor at 8cm dilation. Assessment reveals a prolapsed umbilical cord. which action should the nurse prioritize?

Use fingers to press upward on the presenting part.

A laboring client is experiencing dysfunctional labor or dystocia D/t the malfunction of one or more of the "four P's" of labor. Which scenario best illustrates a power problem?

Uterine contractions are weak and ineffective.