Intrapartal Period: Assessments and Interventions > Level- 3: Competent

The nurse midwife performs Leopold's Maneuvers to determine fetal positioning in the womb. which can the midwife determine by palpating the woman's fundus? 1. If the fetus is breech or vertex 2. The location of the back and fetal small parts 3. The fetal presenting part 4. The location of the cephalic prominence

1. If the fetus is breech or vertex

Following the assessment of a newly-admitted laboring client, the nurse documents the client to be 4cm, 30%, and -3 with contractions every 4 to 5 minutes and lasting 45 seconds. which phase of labor does the nurse assess the client to be in? 1. Second stage 2. Third stage 3. Latent phase 4. Transition phase

3. Latent phase

The student nurse is watching the preceptor coach a client through the second stage of labor. During this stage, the nurse assesses the client for the urge to push and encourages the client to delay pushing until she feels the urge to. The student nurse recognizes this type of second-stage care as which? 1. Directed pushing 2. Spontaneous pushing 3. Nondirected pushing 4. Valsalva pushing

3. Nondirected pushing

Following a vaginal exam on a client in labor, the nurse documents the client to be 8cm, 80%, +1. Which do these terms represent? 1. Cervical effacement, fetal station, cervical dilation 2. Cervical effacement, dilation, fetal station 3. Fetal station, cervical dilation, cervical effacement 4. Cervical dilation, effacement, fetal station

4. Cervical dilation, effacement, fetal station

Upon starting a shift in the labor and delivery unit, the nurse is assigned to care for a 15-year-old client in active labor. When entering the room to assess the client, the nurse finds a room full of visitors and notes the client appears uncomfortable. which is the appropriate nursing intervention at this time? 1. Insist that all visitors leave the room so that it can be a quiet labor environment. 2. Tell the client you will come back to check her blood pressure after everyone leaves. 3. Determine who the visitors are, so the nurse can focus her assessment questions towards the parents of the client. 4. Request that everyone step out during the assessment and ask the client whom she would like in the room for the birth.

4. Request that everyone step out during the assessment and ask the client whom she would like in the room for the birth.

The nurse is assessing a low-risk pregnant client and documenting fetal heart tones every 5 minutes. which stage of labor is this client in, based on the frequency of assessments being performed? 1. Latent phase 2. Early phase 3. First stage 4. Second stage

4. Second stage

During labor and delivery, the fetus passes through the birth canal and must make several movements to allow for successful delivery. Place the following cardinal movements for birth into the correct order. 1 Descent 2 Expulsion 3 Extension 4 Flexion 5 External rotation 6 Engagement 7 Internal rotation

Engagement: When the greatest diameter of the fetal head passes through the pelvic inlet; can occur late in pregnancy or early in labor (see Fig. 8-20A). ● Descent: Movement of the fetus through the birth canal during the first and second stages of labor (see Fig. 8-20A). ● Flexion: When the chin of the fetus moves toward the fetal chest; occurs when the descending head meets resistance from maternal tissues; results in the smallest fetal diameter to the maternal pelvic dimensions; normally occurs early in labor (see Fig. 8-20A). ● Internal rotation: When the rotation of the fetal head aligns the long axis of the fetal head with the long axis of the maternal pelvis; occurs mainly during the second stage of labor (see Fig. 8-20B). ● Extension: Facilitated by resistance of the pelvic floor that causes the presenting part to pivot beneath the pubic symphysis and the head to be delivered; occurs during the second stage of labor (see Fig. 8-20C). ● External rotation/restitution: During this movement, the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis (see Fig. 8-20D). Head and shoulders rotate to move under the symphysis pubis. ● Expulsion: The anterior shoulder usually comes first followed by the remainder of the body (see Fig. 8-20E).

Upon vaginal examination, the nurse notes that the infant's anterior fontanel is to the back left side of the maternal pelvis. How does the nurse chart this position? 1. ROA 2. LOA 3. ROP 4. LOP

Rationales Option 1: The occiput is the landmark used for identifying fetal position. If the anterior fontanel is pointing to the back (posterior) left of the maternal pelvis, then the occiput is pointing toward the right, anterior maternal pelvis.

During labor, nurses provide continuous support to clients. which are the outcomes seen from this support? Select all that apply. 1. Decrease in operative births 2. Increase in likelihood of breastfeeding 3. Decrease in childbirth satisfaction 4. Decrease in pharmacologic pain management 5. Increase in labor length

1, 2, 4

The nurse is caring for a client being augmented with oxytocin. What potential complications should the nurse observe the client for? Select all that apply. 1. Tachysystole 2. Late decelerations on the fetal monitor 3. Episodic accelerations 4. Uterine rupture 5. Maternal edema

1, 2, 4, 5

The nurse is preparing the client for epidural anesthesia. Which assessments or interventions would the nurse perform prior to administration? Select all that apply. 1. Check the platelet level. 2. Perform the procedure time-out. 3. Determine that the client is dilated to at least 5cm. 4. Ensure the consent has been signed. 5. Administer IV fluid bolus of normal saline or lactated ringers.

1, 2, 4, 5

The nurse is assisting a pregnant client, who is placing the baby up for adoption, with the development of a birth plan. which questions would the nurse consider when planning the birth plan? Select all that apply. 1. Will the client spend some time alone with the infant? 2. How involved will the adoptive parents be in the birth? 3. Does the client plan to leave the hospital immediately after delivery? 4. Where are the closest support groups for birth parents? 5. Who will be present at the hospital to support the client?

1, 2, 5

Following a precipitous labor, the obstetrician did not arrive to the hospital in time for the delivery. The nurse is monitoring for the delivery of the placenta. Which indications would result in the nurse asking the client to push to deliver the placenta? Select all that apply. 1. A sudden gush of blood from the vagina 2. Client starts to feel very nauseous 3. Umbilical cord lengthens at the vaginal introitus 4. Uterus rises upward in a ball shape 5. Blood pressure and pulse rate decrease

1, 3, 4

The nurse is preparing a group session for childbirth preparation. The topic will include signs of impending labor. The nurse will include which topics? Select all that apply. 1. Lightening 2. Decreased fetal movement 3. Nesting 4. Bloody show 5. Weight gain

1, 3, 4

The nurse is caring for a client in the first stage labor. To assist the progression of labor, the nurse recommends: 1. Changing positions and sitting upright 2. Maintaining a side-lying position only 3. Receiving an epidural as early as possible so she can relax and rest 4. Limiting visitors at the beside to promote rest

1. Changing positions and sitting upright

The nurse is caring for a laboring client who is waiting for the anesthesiologist to come administer the epidural. Which does the nurse anticipate that the obstetrician will order for this client to prevent a common adverse reaction following the epidural placement? 1. IV fluid bolus 2. Left-tilt position 3. Check vitals every 5 minutes 4. Assist client to bathroom

1. IV fluid bolus

The nurse is assessing a laboring client. Which signs and symptoms does the nurse recognize that indicate movement into the transition phase of labor? Select all that apply. 1. Contractions every 3 to 4 minutes 2. Contractions lasting 60 to 90 seconds 3. Cervix dilated to 8 cm 4. Noted trembling of client 5. Increase in client anxiety

2, 3, 4, 5

The nurse is assessing the APGAR score on an infant at 1 minute of age. The infant has a lusty and vigorous cry with active motion of the extremities. The heart rate is 98 beats per minute. The respirations are 55 per minute, and the oxygen saturation is 98%. Acrocyanosis is noted on the hands and feet. which does the nurse record for the APGAR score? 1. APGAR 10 2. APGAR 8 3. APGAR 9 4. APGAR 7

2. APGAR 8

The nurse is admitting a 16-year-old client for induction. She expresses fear about the pain of labor and delivery. which is the best response by the nurse? 1. "Since you are under 18, your mom will decide what type of pain management is best for you." 2. "You should get an epidural. You won't feel any labor, but pushing may be more difficult." 3. "There are many options for pharmacological and non pharmacological pain relief. I'll discuss the pros and cons with you." 4. "Childbirth classes are a great way to learn about pain relief options. Did you attend any?"

3. "There are many options for pharmacological and non pharmacological pain relief. I'll discuss the pros and cons with you."

Immediately following the delivery of the placenta, the nurse prepares to administer IV oxytocin. The client states, "What is this medication for?" which is the nurse's best response? 1. "To augment labor contractions" 2. "To improve the let-down reflex for your breastmilk." 3. "To prevent hemorrhage after delivery." 4. "To prevent uterine cramping and pain following delivery."

3. "To prevent hemorrhage after delivery."

While caring for a client, which interventions would the nurse include in the nursing care plan to provide culturally competent care? Select all that apply. 1. Describe hospital protocols that will be followed during the delivery. 2. Provide teaching on non-pharmacological pain management options as they are preferred by women of the client's culture. 3. Identify who the woman prefers to care for her during labor and delivery. 4. Provide the client's preferred foods as appropriate or encourage the client's family to bring foods from home. 5. Determine who is the client's support person(s) and how they will participate in her care.

3. Identify who the woman prefers to care for her during labor and delivery. 4. Provide the client's preferred foods as appropriate or encourage the client's family to bring foods from home. 5. Determine who is the client's support person(s) and how they will participate in her care.

A client requests to keep the placenta following delivery. How would the nurse respond to this request? 1. "We do not allow that in this hospital. It is against all regulations." 2. "Can you tell me what you plan to do with the placenta? We only allow this if you plan to bury the placenta." 3. "Why would you want to take that home? It will begin to smell and can attract insects." 4. "I understand that this is very important to you, and I will see what I can do to honor this request."

4. "I understand that this is very important to you, and I will see what I can do to honor this request."

The nurse receives a call from the partner of a client in labor. The partner asks when they should come to the hospital. During which part of labor would a pregnant client be told to come to the hospital? 1. Transition phase 2. Fourth stage 3. Second stage 4. Active phase

4. Active phase