Exam 3 OB prep U questions
A nurse is describing the events of labor to a group of pregnant women. Put the following events of labor as the nurse would explain them from first to last. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. Cervix becomes fully effaced. The cervix dilates to 2 cm. Fetus continues descent. Placenta is expelled. Crowning occurs. Placenta separates.
1The cervix dilates to 2 cm. 2Cervix becomes fully effaced. 3Fetus continues descent. 4Crowning occurs. 5Placenta separates. 6Placenta is expelled.
A pregnant client's labor has been progressing slower than normal. The client is visibly anxious and tense, telling the nurse, "I am so worried about what is going to happen. And I am so tired and feel so helpless." Other underlying issues that may be contributing to the client's slow labor progress have been ruled out. Which response(s) by the nurse would be appropriate? Select all that apply. A. "Maybe dimming the lights or some soft music will help you relax a bit." B. "Let me leave you alone for a little while so you can get some rest." C. "I will keep you updated often on how you and your baby are doing." D. "Things are moving along but sometimes it can take a little longer." E. "I will have to stop giving you pain medicine because it is slowing your labor."
A. "Maybe dimming the lights or some soft music will help you relax a bit." C. "I will keep you updated often on how you and your baby are doing." D. "Things are moving along but sometimes it can take a little longer."
A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? A. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." B. "This is not normal unless you are in active labor; come to the hospital and be checked." C. "That is something we expect with a second or third baby, but because it is your first, you need to be checked." D. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."
A. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? A. Assess and reposition the woman. B. Notify the registered nurse. C. Notify the health care provider. D. Wait 2 minutes to review another tracing.
A. Assess and reposition the woman.
A client has just received combined spinal epidural. Which nursing assessment should be performed first? A. Assess vital signs. B. Assess pain level using a pain scale. C. Assess for progress in labor. D. Assess for spontaneous rupture of membranes. E. Assess for fetal tachycardia.
A. Assess vital signs.
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? A. Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. B. Assist the client to a sitting position, assess the fetal heart rate, give naloxone, and administer oxygen via face mask. C. Assist the client to the supine position, recheck the blood pressure, and administer an IV bolus of 1000 ml. D. Assist the client to Trendelenburg position, assess the fetal heart rate, and administer oxygen via face mask.
A. Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask.
Which documentation in the health record is most correct for the third stage of labor? A. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta. B. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus. C. Begins with the time of placental delivery and ends when the health care provider is satisfied that there are no placental fragments. D. Begins with the time of placental delivery and ends 48 hours later.
A. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.
The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? A. Continuous support through the labor process helps decrease the need for pain medication. B. Sitting in a hot tub helps decrease the need for pain medication. C. A quick epidural can replace the need for pain medication. D. Lying on an ice pack can help decrease the need for pain medication.
A. Continuous support through the labor process helps decrease the need for pain medication.
Which cardinal movement of delivery is the nurse correct to document by station? A. Descent B. Flexion C. Extension D. Internal rotation
A. Descent
While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents? A. FHR fluctuates from 6 to 25 beats per minute. B. FHR fluctuation range is undetectable. C. FHR fluctuates less than 5 beats per minute. D. FHR fluctuates over 25 beats per minute.
A. FHR fluctuates from 6 to 25 beats per minute.
The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first? A. Feel for the fetal buttocks or head while palpating the abdomen. B. Feel for the fetal back and limbs as the hands move laterally on the abdomen. C. Palpate for the presenting part in the area just above the symphysis pubis. D. Determine flexion by pressing downward toward the symphysis pubis.
A. Feel for the fetal buttocks or head while palpating the abdomen.
How does a woman who feels in control of the situation during labor influence her pain? A. Feelings of control and being prepared for labor and birth are inversely related to the client's report of pain. B. Decreased feeling of control helps during the third stage. C. There is no association between the two factors. D. Feeling in control shortens the overall length of labor.
A. Feelings of control and being prepared for labor and birth are inversely related to the client's report of pain.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? A. Fetal heart rate in relation to contractions B. The station in which the fetus is located C. Maternal heart rate and blood pressure D. Maternal request for pain medication
A. Fetal heart rate in relation to contractions
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? A. Help the woman change positions. B. Obtain assistance to check for a compressed umbilical cord. C. Prepare the woman for an emergency cesarean birth. D. Document the finding.
A. Help the woman change positions.
The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring? A. Intermittent fetal heart rate auscultation B. Continuous external fetal monitor C. No monitoring needed D. Fetal scalp sampling
A. Intermittent fetal heart rate auscultation
Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply. A. Monitor maternal and fetal vital statistics every hour. B. Report an elevated temperature over 38℃ (100.4℉). C. Answer questions and encourage verbalization of fears. D. Have a client remain on bed rest with bathroom privileges only. E. Position client on the left side throughout the labor process.
A. Monitor maternal and fetal vital statistics every hour. B. Report an elevated temperature over 38℃ (100.4℉). C. Answer questions and encourage verbalization of fears.
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? A. Nothing. Normal time for stage three is 5 to 30 minutes. B. Notify the primary care provider of the problem. C. Increase the IV tocolytic to help in expulsion of the placenta. D. Do a vaginal exam to see if the placenta is stuck in the birth canal.
A. Nothing. Normal time for stage three is 5 to 30 minutes.
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? A. Pain originates from the cervix and lower uterine segment. B. It is reported as the worst pain a woman will ever feel. C. Pain is focal in nature. D. Diffuse abdominal pain signals a complication with progression of labor.
A. Pain originates from the cervix and lower uterine segment.
The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record? A. Precipitous labor B. Prolonged labor C. Prodromal labor D. False Labor
A. Precipitous labor
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? A. Radiates from the back to the front B. Slows when the woman changes position C. Occurs in an irregular pattern D. Lasts about 20 to 25 seconds
A. Radiates from the back to the front
The nurse would prepare a client for amnioinfusion when which action occurs? A. Severe variable decelerations occur and are due to cord compression. B. Fetal presenting part fails to rotate fully and descend in the pelvis. C. The fetus shows abnormal fetal heart rate patterns. D. Maternal pushing is compromised due to anesthesia.
A. Severe variable decelerations occur and are due to cord compression.
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. A. Turn the client on her left side. B. Reduce intravenous (IV) fluid rate. C. Administer oxygen by mask. D. Assess client for underlying causes. E. Ignore questions from the client.
A. Turn the client on her left side. C. Administer oxygen by mask. D. Assess client for underlying causes.
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? A. Use a birthing ball and find a position of comfort. B. Stay low on her back to ease the back pain. C. Use the Valsalva maneuver for effective pushing. D. Ask for privacy, and have just the partner present.
A. Use a birthing ball and find a position of comfort.
The nurse is assisting a primipara in the second stage of labor. The mother has been pushing now for almost 3 hours. The nurse should anticipate planning for: A. an operative delivery. B. augmentation with oxytocin. C. an increase in the epidural medication. D. a variation in pushing technique.
A. an operative delivery.
A pregnant client is being discharged from the labor and birth suite because of false labor. The client asks the nurse how to tell whether the contractions are true contractions or Braxton Hicks contractions. Which description(s) will the nurse mention as characteristic of true contractions? Select all that apply. A. begin irregularly but become regular and predictable B. felt first in lower back and sweep around to the abdomen in a wave C. increase in duration, frequency, and intensity D. begin and remain irregular E. felt first abdominally and remain confined to the abdomen and groin F. often disappear with ambulation or sleep
A. begin irregularly but become regular and predictable B. felt first in lower back and sweep around to the abdomen in a wave C. increase in duration, frequency, and intensity
A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? A. cesarean birth B. administration of oxytocin C. administration of morphine sulfate D. darkening room lights and decreasing noise and stimulation
A. cesarean birth
A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The health care provider suspects the client has amniotic fluid embolism. What other sign(s) or symptom(s) alerts the nurse to the presence of this condition in the client? Select all that apply. A. cyanosis B. arrhythmia C. hyperglycemia D. coagulopathy E. pulmonary edema
A. cyanosis D. coagulopathy E. pulmonary edema
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? A. decreased alertness B. increased agitation C. low Apgar D. increased crying
A. decreased alertness
The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. A. determining the presentation of the fetus B. determining the position of the fetus C. determining the lie of the fetus D. determining the weight of the fetus E. determining the size of the fetus
A. determining the presentation of the fetus B. determining the position of the fetus C. determining the lie of the fetus
A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? A. external cephalic version B. trial labor C. forceps birth D. vacuum extraction
A. external cephalic version
As a woman enters the second stage of labor, which would the nurse expect to assess? A. feelings of being frightened by the change in contractions B. reports of feeling hungry and unsatisfied C. falling asleep from exhaustion D. expressions of satisfaction with her labor progress
A. feelings of being frightened by the change in contractions
A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds? A. fetal back B. fetal head C. fetal shoulders D> fetal buttocks
A. fetal back
A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? A. hypotonic contractions B. hypertonic contractions C. uncoordinated contractions D. Braxton Hicks contractions
A. hypotonic contractions
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. A. increase in heart rate B. increase in blood pressure C. increase in respiratory rate D. slight decrease in body temperature E. increase in gastric emptying and pH
A. increase in heart rate B. increase in blood pressure C. increase in respiratory rate
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. A. lightening B. weight gain C. constipation D. bloody show E. backache
A. lightening D. bloody show E. backache
A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands that which factors are causing the extreme pain in the client? Select all that apply. A. lower uterine segment distention B. fetus moving along the birth canal C. stretching and tearing of structures D. spontaneous placental expulsion E. dilation (dilatation) of the cervix
A. lower uterine segment distention C. stretching and tearing of structures E. dilation (dilatation) of the cervix
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? A. magnesium sulfate B. nifedipine C. indomethacin D. betamethasone
A. magnesium sulfate
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? A. meperidine B. thiopental C. hydroxyzine hydrochloride D. secobarbital
A. meperidine
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? A. pain from the dilation (dilatation) or stretching of the cervix B. hypoxia of the contracting uterine muscles C. distention of the vagina and perineum D. pressure on the lower back, buttocks, and thighs
A. pain from the dilation (dilatation) or stretching of the cervix
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? A. progressive cervical dilation (dilatation) and effacement B. pink show C. increased fetal activity D. 1:5 uterine contractions
A. progressive cervical dilation (dilatation) and effacement
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? A. providing a comfortable environment with dim lighting B. administering oxytocin C. preparing the woman for an amniotomy D. encouraging the women to change positions frequently
A. providing a comfortable environment with dim lighting
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? A. respiratory rate B. temperature C. pulse D. uterine contractions
A. respiratory rate
A G3P2 woman arrives at the birthing center stating that she has been in labor for the past 18 hours. The nurse suspects a protracted labor pattern disorder based on which finding? A. slower than usual cervical dilation (dilatation) B. poor contraction quality and intensity C. incomplete relaxation of the uterus between contractions D. fetal face presentation
A. slower than usual cervical dilation (dilatation)
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? A. transition phase B. latent phase C. active phase D. early phase
A. transition phase
A client with a pendulous abdomen and uterine fibroids (uterine myomas) has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? A. transverse lie B. anterior fetal position C. cephalic presentation D. occipitoposterior position
A. transverse lie
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. A. uterine resting tone B. frequency of contractions C. change in temperature D. change in blood pressure E. intensity of contractions
A. uterine resting tone B. frequency of contractions E. intensity of contractions
A nurse is caring for a 16-year-old primigravida client who is in active labor. The client did not attend prenatal classes and nervously asks the nurse to explain to what will happen. The nurse performs a focused assessment to determine the stage of labor and then explains the different phases of the first stage of labor. The nurse determines client understanding when they correctly identifies how each phase differs. For each finding, click to specify if the finding indicates a latent or active phase of the first stage of labor. Findings: contractions 2 to 3 minutes apart, strong to very strong rapid dilation and effacement contractions irregular, mild to moderate contraction duration 45 to 90 seconds contractions 5 to 30 minutes apart contraction duration 30 to 45 seconds start of fetal descent complete dilation and effacement cervical dilation 4 to 7 cm
ACTIVE -contractions 2 to 3 minutes apart, strong to very strong -rapid dilation and effacement -contraction duration 45 to 90 seconds -start of fetal descent -complete dilation and effacement -cervical dilation 4 to 7 cm LATENT -contractions irregular, mild to moderate -contractions 5 to 30 minutes apart -contraction duration 30 to 45 seconds
At which time is it most important to monitor for umbilical cord prolapse? A. At the onset of labor B. After rupture of membranes C. During transitional labor D. When the fetus is crowning
B. After rupture of membranes
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? A. Braxton Hicks contractions get closer together with activity. B. Braxton Hicks contractions usually decrease in intensity with walking. C. Braxton Hicks contractions do not last long enough to be true labor. D. Braxton Hicks contractions cause "ripening" of the cervix.
B. Braxton Hicks contractions usually decrease in intensity with walking.
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? A. Bloody fluid B. Clear to straw-colored fluid C. Greenish fluid D. Cloudy white fluid
B. Clear to straw-colored fluid
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? A. Shorter dilation (dilatation) stage of labor B. Experience of additional back pain C. Need to have the baby manually rotated D. Necessity for vacuum extraction for birth
B. Experience of additional back pain
The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started? A. Increase oral fluids B. IV fluid bolus C. Monitor temperature D. Monitor maternal apical pulse
B. IV fluid bolus
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? A. Immersing the client in warm water in a pool or hot tub B. Practicing effleurage on the abdomen C. Administering a sedative such as secobarbital or pentobarbital D. Administering an opioid such as meperidine or fentanyl
B. Practicing effleurage on the abdomen
The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? A. Bradypnea B. Sudden shortness of breath C. Bradycardia D. Unrelieved pain
B. Sudden shortness of breath
A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? A. Suggest a less extreme alternative such as a sedative. B. Support the client's decision and call the provider. C. Gently remind the client of her goal of a natural birth and encourage and help her. D. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her.
B. Support the client's decision and call the provider.
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? A. The contraction pains are 2 minutes apart and 1 minute in duration. B. The client reports back pain, and the cervix is effacing and dilating. C. The contraction pains have been present for 5 hours, and the patterns are regular. D. After walking for an hour, the contractions have not fully subsided.
B. The client reports back pain, and the cervix is effacing and dilating.
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? A. This would cause fetal depression in utero. B. This may prolong labor and increase complications. C. The effects would wear off before birth. D. This can lead to maternal hypertension.
B. This may prolong labor and increase complications.
A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? A. Place the client supine with the head of bed elevated 30 degrees. B. Use a fist to apply counterpressure to the lower back. C. Apply a warm washcloth to the lower back. D. Have the health care provider administer a pudendal block.
B. Use a fist to apply counterpressure to the lower back.
Touch and massage can be helpful during labor. Which touch and massage methods are used in labor? Select all that apply. A. patterned breathing B. effleurage C. counterpressure D. water therapy
B. effleurage C. counterpressure
A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess? A. uterine abnormalities B. fetal anomalies C. congenital anomalies D. birth after due date
B. fetal anomalies
At 31 weeks' gestation, a 37-year-old client with a history of preterm birth reports cramps; vaginal pain; and a low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals the cervix is 2.1 cm long and dilated 3 to 4 cm and fetal fibronectin in cervical secretions. Which set of interactions should the nurse prepare to assist with? A. bed rest and hydration at home B. hospitalization, tocolytic, and corticosteroids C. an emergency cesarean birth D. careful monitoring of fetal movement (kick) counts
B. hospitalization, tocolytic, and corticosteroids
The nurse is caring for a client who required a forceps-assisted birth. For which potential factor should the nurse be alert? A. increased risk for uterine rupture B. potential lacerations and bleeding C. increased risk for cord entanglement D. damage to the pregnant client's tissues
B. potential lacerations and bleeding
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? A. variable decelerations B. prolonged decelerations C. early decelerations D. accelerations
B. prolonged decelerations
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? A. accidental intrathecal block B. respiratory depression C. postdural puncture (spinal) headache D. a failed block
B. respiratory depression
The nurse is monitoring a pregnant client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? A. latent B. second C. third D. active
B. second
A client in labor had no change in cervical dilation (dilatation) over the past 2 hours. The health care provider performs an amniotomy. Based on the chart above, what should the nurse do first after the amniotomy? A. Provide perineal care. B. Document amniotic fluid color and amount. C. Assess fetal heart rate. D. Assist with position change.
C. Assess fetal heart rate.
The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor? A. Patterned birthing B. Water therapy C. Attention focusing D. Hypnosis
C. Attention focusing
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? A. Administer oxygen. B. Increase her IV fluids. C. Change the position of the client. D. Notify the primary care provider.
C. Change the position of the client.
The nurse is admitting a client who is in early labor and who's membranes just ruptured. After determining that the birth is not imminent, which assessment should the nurse perform next? A. Risk factors and fetal position B. Maternal status and signs of infection C. Fetal status and FHR D. Maternal obstetrical history and maternal comfort level
C. Fetal status and FHR
Which cardinal movement allows the fetus to travel through the birth canal most efficiently? A. Extension B. External rotation C. Flexion D. Engagement
C. Flexion
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? A. Fetal heart rate B. Possible maternal infection C. Green-colored fluid in the vagina D. Irregular contractions
C. Green-colored fluid in the vagina
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? A. Monitor heart rate for tachycardia. B. Monitor fetal movements to ensure they are neurologically intact. C. Look for late decelerations on monitor, which is associated with fetal anoxia. D. Monitor fetal blood pressure for signs of shock (low BP, high FHR).
C. Look for late decelerations on monitor, which is associated with fetal anoxia.
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia? A. McDonald maneuver B. McGeorge maneuver C. McRoberts maneuver D. McRonald maneuver
C. McRoberts maneuver
A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement? A. Assist in preparation for a cesarean birth. B. Assist in providing epidural anesthesia. C. Provide emotional and physical support. D. Administer the drug naloxone.
C. Provide emotional and physical support.
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize? A. Past obstetrical history B. Fetal status C. Signs that birth is imminent D. Client's temperature
C. Signs that birth is imminent
Which assessment finding is most important as labor progresses? A. The client is remaining in control of emotions. B. Labor is completed within 18 hours. C. The uterus relaxes completely between contractions. D. The pulse and respirations rise with the work of labor.
C. The uterus relaxes completely between contractions.
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? A. First B. Second C. Third D. Fourth
C. Third
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of the frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? A. perineal phase B. latent phase C. active phase D. pelvic phase
C. active phase
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? A. application of vibroacoustic stimulation B. tactile stimulation C. administration of oxygen by mask D. fetal scalp stimulation
C. administration of oxygen by mask
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: A. internal rotation, descent, extension, flexion, external rotation, expulsion B. descent, flexion, external rotation, extension, internal rotation, expulsion C. descent, flexion, internal rotation, extension, external rotation, expulsion D. internal rotation, flexion, descent, extension, external rotation, expulsion
C. descent, flexion, internal rotation, extension, external rotation, expulsion
At which time interval will the nurse assess the fetal heart rate of pregnant clients who are in the early active phase of labor? A. every 2 to 4 hours B. every 45 to 60 minutes C. every 15 to 30 minutes D. every 10 to 15 minutes
C. every 15 to 30 minutes
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor? A. second B. first, latent C. first, active D. third
C. first, active
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? A. maternal hypotension and fetal tachycardia B. maternal hypertension and fetal bradycardia C. maternal hypotension and fetal bradycardia D. maternal hypertension and fetal tachycardia
C. maternal hypotension and fetal bradycardia
A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: A. occurring in the abdomen and groin. B. lasting about 30 seconds. C. occurring about every 5 minutes. D. relieved by walking.
C. occurring about every 5 minutes.
A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? A. to reduce boggy nature of the uterus B. to remove pieces left attached to uterine wall C. to constrict the uterine blood vessels D. to lessen the chances of conducting an episiotomy
C. to constrict the uterine blood vessels
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses "arrest of labor." The woman asks, "Why is this happening?" Which response is the best answer to this question? A. "Maybe your uterus is just tired and needs a rest." B. "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." C. "Maybe your baby has developed hydrocephaly and the head is too swollen." D. "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
D. "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
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? A. 5.0 B. 5.5 C. 6.0 D. 6.5
D. 6.5
A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? A. Administer oxytocin in a 20 cc bolus of saline. B. Administer oxytocin in two divided intramuscular sites. C. Administer oxytocin diluted in the main intravenous fluid. D. Administer oxytocin diluted as a "piggyback" infusion.
D. Administer oxytocin diluted as a "piggyback" infusion.
A client in labor with epidural analgesia is fully dilated and preparing to push. The nurse palpates a smooth, firm, oval bulge in the suprapubic area. What action should the nurse take first? A. Perform an in-and-out catheterization. B. Notify the health care provider of an occiput posterior position. C. Assess the fetal heart rate. D. Have the client attempt to void.
D. Have the client attempt to void.
A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize? A. Assess maternal and fetal vital signs. B. Ask medical and obstetrical history. C. Escort to Labor and Delivery. D. Quickly evaluate the perineum.
D. Quickly evaluate the perineum.
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize? A. Level of consciousness B. Blood pressure C. Maternal heart rate D. Respiratory status
D. Respiratory status
A nurse is monitoring a client in labor. Which assessment finding is most concerning to the nurse? A. Client begins vomiting. B. Blood pressure is 128/82 mm Hg. C. Respiratory rate is 22 breaths/minute. D. Temperature is 101.6°F (38.7°C).
D. Temperature is 101.6°F (38.7°C).
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? A. Cord compression B. Maternal hypotension C. Maternal fatigue D. Uteroplacental insufficiency
D. Uteroplacental insufficiency
A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth? A. extensive lacerations B. monitor for a cardiac anomaly C. assess for cleft palate D. brachial plexus assessment
D. brachial plexus assessment
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction? A. lack of cervical dilation past 2 cm B. fetal buttocks as the presenting part C. reports of severe back pain D. contractions most forceful in the middle of uterus rather than the fundus
D. contractions most forceful in the middle of uterus rather than the fundus
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? A. diffuse abdominal cramping B. rupturing of fetal membranes C. start of regular contractions D. dilation (dilatation) of cervix diameter to 10 cm
D. dilation (dilatation) of cervix diameter to 10 cm
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? A. a shallow deceleration occurring with the beginning of contractions B. variable decelerations, too unpredictable to count C. fetal baseline rate increasing at least 5 mm Hg with contractions D. fetal heart rate declining late with contractions and remaining depressed
D. fetal heart rate declining late with contractions and remaining depressed
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? A. genetic abnormality B. premature rupture of membranes C. preeclampsia D. placental abruption
D. placental abruption
During the second stage of labor, a woman is generally: A. very aware of activities immediately around her. B. anxious to have people around her. C. no longer in need of a support person. D. turning inward to concentrate on body sensations.
D. turning inward to concentrate on body sensations.
A client in active labor with a history of two previous cesarean births is being monitored frequently as they try to have a vaginal birth. Suddenly, the client grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes the client's blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication? A. compression on the inferior vena cava B. amniotic embolism to the lungs C. undiagnosed abdominal aorta aneurysm D. uterine rupture
D. uterine rupture
