INTRAPARTUM

A nurse is teaching a primipara and her partner about the labor and birth process. The nurse describes the maneuvers that the fetus goes through during the labor process when the head is the presenting part. Place the maneuvers below in the order in which the nurse should explain that they occur. .Internal rotation Flexion Descent Engagement

1. Engagement 2. descent 3. flexion 4. Internal rotation

A nurse is monitoring a full-term laboring client on oxytocin. What interventions would be priorities for the nurse if the client experiences late decelerations? Select all that apply. A. Give oxygen. B. Report the findings to the heath care professional (HCP). c. Perform a vaginal examination for prolapsed cord. D. Position the client on her left side. E. Stop the infusion of oxytocin.

A. Give oxygen B. Report the findings to the health care professional D. Position the client on the left side E. Stop infusion of oxytocin

A nurse is teaching a group of clients in a prenatal class about fetal monitor decelerations. The nurse knows the teaching is effective when the clients list what as common causes for decelerations on a fetal monitor? Select all that apply. A. maternal position B. prematurity C. placental insufficiency D. cord compression E. head compression

A. Maternal position C. Placental insufficiency D. Cord compression E. Head compression

The labor and delivery nurse is admitting a client at 39 weeks' gestation who is in early labor. The nurse performs the Leopold maneuver and discovers the fetus is in a transverse lie. What action(s) should the nurse take based on this information? Select all that apply. A. Notify the health care provider. B. Place the doppler for monitoring fetal heart rate (FHR). C.. Establish intravenous access. D. Draw blood for complete blood count, type, and crossmatch. E. Notify anesthesia for STAT epidural.

A. Notify HCP B. place the doppler for monitoring FHR C. Establish IV access D. Draw blood for CBC, type and cross match

A nurse is assigned to assist with the admission of a laboring client. Which of the following actions are appropriate? Select all that apply. asking about the estimated date of childbirth estimating fetal size taking maternal and fetal vital signs asking about the woman's last menses administering an analgesic asking about the amount of time between contractions

Asking about the estimated age of childbirth Taking maternal and fetal VS Asking about the amount of time between contractions

A laboring client has an epidural anesthesia. Which of the following would be the priority interventions related to the maintenance of epidural anesthesia? Select all that apply. Assess blood pressure every 30 minutes, and every 5 minutes with each bolus. Assess for prolonged second stage of labor. Administer oxygen 10 liters by mask. Use a hip wedge if the client is positioned supine. Elevate legs above heart level.

Assess BP every 30 mins and every 5 mins with every bolus Assess prolonged second stage of labor Use a hip wedge if the client positioned supine

What action(s) 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 administering oxytocin assisting with perineal repairs drying the newborn initiating skin-to-skin care taking newborn vital signs

Assigning APGAR scores Drying newborn Initiate skin-skin care Taking newborn VS

The triage nurse is giving a telephone report to the receiving nurse in the labor and birth unit. The multigravida client is 8 cm dilated and is being transferred to the labor and birth unit. How should the labor and birth nurse manage the next 10 minutes with the client? Select all that apply. Begin fetal monitoring. Call other staff to set up the birthing table. Assess the comfort needs of the client. Determine support systems for the client. Prepare to give an early report to the nurse arriving on the next shift.

Begin fetal monitoring Call other staff to set up birthing table Assess the comfort needs of client Determine support system of client

A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block? Select all that apply. Make sure oxygen is available. Keep the client positioned on her left side. Monitor vital signs frequently. Maintain intravenous (IV) fluid at a keep-vein-open rate. Monitor fetal heart rate and contractions closely.

Make sure oxygen is available Monitoring VS frequently Monitor FHR and contractions closely

The nurse is preparing to assist the health care provider (HCP) with a check of the cervix for a client whose membranes have ruptured. What equipment should the nurse have ready for the HCP? Select all that apply. sterile speculum sterile gloves sterile lubricant intrauterine pressure catheter cervical dilators

Sterile gloves Sterile lubricant

The nurse is caring for a client with abruptio placenta. What signs and symptoms of abruptio placenta would be expected when collecting data on this client? Select all that apply. vaginal bleeding decreased fundal height uterine tenderness on palpation soft abdomen on palpation hypotonic, small uterus abnormal fetal heart tones

Vaginal bleeding Uterine tenderness on palpation Abnormal Fetal heart tones

The nurse is discussing pain relief methods for a pregnant first-time parent. The discussion should include which labor support method(s)? Select all that apply. effleurage positive reinforcement guided imagery pattern-paced breathing progressive relaxation

effleurage guided imagery pattern-paced breathing Progressive relaxation

The nurse has obtained a urine specimen from a multiparous client admitted to the labor unit. The client asks to go to the bathroom and reports that they feel the need for a bowel movement. Which action(s) would be appropriate? Select all that apply. assisting the client to the bathroom applying an external fetal monitor to obtain the fetal heart rate assessing the client's stage of labor asking the client if they had back labor pains like this with any previous birth experiences allowing the client a support person to take them to the bathroom to maintain privacy checking the degree of fetal descent

Assessing the client's stage of labor Checking the degree of fetal descent

A client who is 29 weeks pregnant comes to the labor and childbirth unit. She states that she is having contractions every 8 minutes. The client is also 3 cm dilated. Which can the nurse expect to administer? Select all that apply. A. folic acid B. a β-2 agonist C. betamethasone D. Rohm(D) immune globulin (RhoGAM) E. intravenous fluids F. nalbuphine

B, C, E

A client is receiving oxytocin to induce labor. Which assessment findings indicate common adverse reactions? Select all that apply. blood pressure increased from baseline uterine tetany jaundice heart rate decreased from baseline variable decelerations

Blood pressure increased from baseline Uterine tetany Variable decelerations

While a client is being admitted to the birthing unit they state, "My water broke last night, but my labor started 2 hours ago." Which finding(s) would be a concern? Select all that apply. A. maternal vital signs: temperature 99.5°F (37.5°C); heart rate 80 bpm; respiration 24 breaths/min; blood pressure 130/80 mm Hg B. blood and mucus on the perineal pad C. baseline fetal heart rate of 140 bpm with a range between 110 and 160 bpm with contractions D. peripad stained with green fluid E. client stating, "This baby wants out—he keeps kicking me."

C. Baseline FHR of 140 bpm with a range between 110-160 bpm with contractions D. Peripad stained with green fluid E. Client stating "this baby wants out- he keeps kicking"

A client in labor is 8 cm dilated. The fetus, which is in vertex presentation, is 75% effaced and is at 0 station... meaning the head is at the __________ __________

Ischial spines

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows moderate variability with a baseline of 142 beats per minute (bpm). What interventions should the nurse include in the client's plan of care? Select all that apply. providing encouraging labor support administering oxygen via face mask changing the client's position increasing the client's I.V. rate documenting the findings

Providing encouraging labor support Documenting findings

The nurse is caring for a client in labor. Which assessment findings would prompt the nurse to notify the healthcare provider? Select all that apply. The client is moaning in pain during contractions. The fetal heart rate baseline is between 140 and 150 beats/minute. The client is anxious and requests that someone help her. The client's membranes rupture and the amniotic fluid is green. Late decelerations are noted on the external fetal monitor strip. Blood-tinged mucous is noted upon internal examination.

The client's membranes rupture and the amniotic fluid is green. Late decelerations are noted on the external fetal monitor strip.

What assessment findings indicate that the multiparous client is in the transitional phase of the first stage of labor? Select all that apply. cervix dilated to 8 cm cervix effaced at 80% contractions occurring every 5-10 minutes and last approximately 60 seconds fetal presenting part at the -1 station contractions hard by palpation

cervix dilated to 8 cm\ cervix effaced at 80% contractions hard by palpation

he nurse is performing an assessment of a client progressing through labor. Place the following findings in the order in which they occur. All options must be used. Strong Braxton Hicks contractions Mild contractions lasting 20-40 seconds Cervical dilation of 7cm 100% cervical effacement Uncontrollable urge push

1. Strong braxton hicks 2. Mild contractions lasting 20-40 seconds 3. cervical dilation of 7 cm 4. 100% cervical effacement 5. Uncontrollable urge to push

A client is a primigravida in early labor. She tells the nurse that she is worried about pain control as her contractions are becoming stronger, and she asks the nurse about the use of narcotics. Which of the following is the nurse's appropriate response about the use of narcotics? Select all that apply. "Narcotics cause variable fetal heart rate accelerations." "Narcotics can decrease uterine activity." "Narcotics will require that the newborn is given naloxone upon birth." "Narcotics are very effective in early labor." "Narcotics may prolong labor if given too early."

"Narcotics can decrease uterine activity" "Narcotics may prolong labor if given too early"

After several hours of induction with intravenous oxytocin administered along with a primary intravenous solution of lactated Ringer's solution, assessment of a primigravida at 42 weeks' gestation reveals a fetal heart rate near the baseline at 120 bpm and strong contractions occurring every 2 to 2.5 minutes and lasting 90 to 100 seconds. In what order from first to last should the nurse perform the required actions?

1. Stop infusion 2. Position the client in lateral position 3. Increase primary IV rate 4. Contact THE PCP

A registered nurse is delegating the monitoring of a client who is receiving oxytocin to induce labor to a new graduate nurse. When discussing adverse side effects of oxytocin, which conditions would the graduate nurse notify the registered nurse of immediately? Select all that apply. a blood pressure of 170/92 mm Hg jaundice in the sclera lab work suggesting dehydration fluid overload with crackles in the lung fields palpable uterine tetany a heart rate of 60 beats/minute

A BP of 170/92 Fluid overload with crackles in the lung fields Palpable uterine tetany

The health care provider (HCP) has performed an amniotomy on a laboring client. Which detail(s) must be included in the documentation of this procedure? Select all that apply. A. time of the rupture B. color and clarity of the fluid C. fetal heart rate (FHR) and the pattern before and after the procedure D. size of amnio hook used during the procedure E. odor and amount of fluid

A. Time of the rupture B. Color and clarity of the fluid C. Fetal heart rate and the pattern before and after procedure E. Odor and amount of amniotic fluid

The nurse assesses a primiparous client with ruptured membranes who has been in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the client with this wave pattern. Which intervention(s) should the nurse perform? Select all that apply. administering oxygen via mask to the client questioning the client about the effectiveness of pain relief placing the client on their side readjusting the monitor to a more comfortable position applying an internal fetal monitor

Administer oxygen via mask to the client Placing client on their side Applying internal fetal monitoring

The nurse is caring for a client in labor who states that she is concerned about needing an episiotomy. Which intervention(s) will the nurse include in the client's plan of care? Select all that apply. A. encourage pushing as soon as the client is completely dilated B. have client avoid the lithotomy position while pushing C. place warm or hot compresses on the perineum D. encourage client to use side-lying position for pushing E. encourage a gradual expulsion of the fetus

B. Have client avoid the lithomy position C. Place warm or hot compress on perineum D. Encourage client to use side lying position for pushing E. Encourage gradual expulsion of fetus

The nurse is caring for a client in early labor. The client reports sudden abdominal pain and is noted to have bright red bleeding. What would the nurse include in the client's plan of care? Select all that apply. Examine the fetal heart monitoring tracing. Call the healthcare provider. Administer oxygen to the client. Examine the client's cervix. Discontinue the IV fluid.

Examine the fetal heart monitoring Call the healthcare provider Administer oxygen to the client

The nurse is caring for a client during the second stage of labor. What interventions would the nurse include in the client's plan of care? Select all that apply. explaining the pushing techniques administering nalbuphine I.V. encouraging ambulation continuing to monitor fetal heart tones asking visitors to leave the room

Explain pushing techniques Continuing to monitor fetal heart tones

The nurse is caring for a client who is in the third stage of labor. Which behaviors by the client does the nurse assess as expected at this stage? Select all that apply. excited about the anticipated process focused on the neonate's condition exhausted from continued pushing reports discomfort from uterine cramping apprehension about the process feeling embarrassed about an urge to defecate

Focused on neonate condition reports discomfort from uterine cramping

the nurse is caring for a client at 39 weeks' gestation who is being induced with oxytocin. Which of the following are maternal and fetal side effects that the nurse should report to the healthcare provider? Select all that apply. hyperstimulation of the uterus water intoxication fetal accelerations cephalopelvic disproportion moderate variability in fetal tracing

Hyperstimulation of the uterus Water intoxication Cephalopelvic disproportion

The nurse is caring for a client at 39 weeks' gestation who is being induced with oxytocin. Which of the following are maternal and fetal side effects that the nurse should report to the healthcare provider? Select all that apply. hyperstimulation of the uterus water intoxication fetal accelerations cephalopelvic disproportion moderate variability in fetal tracing

Hyperstimulation of the uterus Water intoxication Cephalopelvic disproportion

The nurse is caring for a client in labor who has requested epidural anesthesia. Which will the nurse include in the client's plan of care? Select all that apply. infusing fluid bolus prior to epidural anesthesia monitoring blood pressure every 4 hours applying continuous external fetal heart monitoring applying oximetry during insertion of epidural anesthesia maintaining client in a Fowler's position after epidural insertion

Infusing fluid bolus prior to epidural anesthesia applying continuous external Fetal monitoring Applying oximetry during insertion of epidural anesthesia

A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply. interpretation of the fetal monitor strip analgesia or anesthesia being used previous methods of birth control support persons with the client prior birth history

Interpretation of the fetal monitor strip Analgesia or anesthesia being used support person with the client Prior birth hx

The nurse is caring for a client in labor who has been administered epidural anesthesia. Which of the following interventions will the nurse include in the client's plan of care? Select all that apply. Monitor for hypotension. Discontinue the epidural if pruritus is noted. Assess for respiratory depression. Administer an antiemetic if nausea or vomiting is present. Give intravenous medication for breakthrough pain.

Monitor Hypotension Assess respiratory depression Administer an antiemetic if N/V is present

The nurse is caring for a client who is in active labor. The client states, "I think my water just broke!" The fetal heart rate shows a prolonged variable deceleration to 80 beats per minute. The nurse performs a sterile vaginal exam and feels a pulsating cord in the vaginal canal. What are the nurse's priority interventions at this time? Select all that apply. Insert an indwelling catheter to empty the patient's bladder. Move the client's bed into Trendelenburg position. Have the patient's family call for help. Keep fingers in the vagina to keep pressure off of the cord. Have the anesthetist insert an epidural for pain control. Clip any hair from the surgical site.

Move the client's bed into Trendelenburg Have patient's family call for help Keep fingers in the vagina to keep pressure off the cord

A client in labor is given 25 mg of intravenous (IV) meperidine for labor pain. The nurse should monitor the client for which adverse effects of the drug? Select all that apply. hypertension nausea and vomiting respiratory depression urinary incontinence tachycardia

Nausea and vomit Respiratory depression Tachycardia

The nurse receives the following report on a client: "This is a 25-year-old G2P1 with contractions every 3 to 4 minutes lasting 60 seconds. The fetal heart tracing shows the baseline to be 125 with moderate variability. Membranes ruptured 2 hours ago and the cervix is 5 cm, 90% effaced, with a station of -2. The presenting part is engaged." What interventions would the nurse include in the client's plan of care? Select all that apply. Assist the client in pushing techniques. Offer a back rub or effleurage. Place a cool cloth on the client's forehead. Assess temperature every 4 hours. Place the client on bed rest.

Offer a back rub or effulge Place a cool cloth on the client's forehead

The nurse is caring for a client in labor who is 8 cm dilated. What interventions will the nurse include in the client's plan of care? Select all that apply. Administer butorphanol tartrate IV push. Teach infant feeding options. Offer ice chips as needed. Encourage the client to push. Continue to encourage the client.

Offer ice chips as needed. Continue to encourage the client.

The nurse is working on a labor and delivery unit, and is precepting a new graduate nurse. The graduate asks the preceptor, "Is oxytocin used for pain in labor and delivery?" What is the best response by the preceptor? Select all that apply. "Oxytocin is used for amenorrhea." "Oxytocin is used to control postpartum bleeding." "Oxytocin is used to stimulate breast milk ejection." "Oxytocin is used for labor induction." "Oxytocin is used to prevent pregnancy."

Oxytocin is used to control PP bleeding Oxytocin is used to stimulate breast milk Oxytocin is used for labor induction

A primigravida states, "I think my water just broke." What should the nurse do? Select all that apply. Perform a nitrazine test to confirm that the membranes are ruptured. Monitor the fetal heart rate and pattern. Assess maternal temperature. Tell the client that birth will most likely occur within the next hour. Prepare the client for childbirth.

Perform a nitrazine test to confirm Monitor FHR Assess maternal temp