Intrapartum Period - PassPoint
The nurse cares for a client on the labor and delivery unit who identifies as nonbinary and has asked to be referred to using nongendered pronouns. The nurse informs the unlicensed assistive personnel (UAP) who responds, "She's having a baby! Clearly, she's a female. This is ridiculous." How should the nurse respond? Select all that apply.
"Are you saying you will not use the client's requested gender-related language during the shift?" "Remember, you will address the client by their name when delivering care, so pronouns will not be used often." "Gender is different from biological sex designations. I can explain how to use an inclusive approach."
The nurse admits a client in active labor at 38 weeks gestation. The client says to the nurse, "I was not expecting to go into labor so soon, so I did not have time to shave down there." How should the nurse respond?
"It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?"
The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first?
"What is your expected due date?"
A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response?
"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."
A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion?
135 beats/minute
A health care provider has ordered an IV of 5% dextrose in lactated Ringer's solution at 125 mL/hour. The IV tubing delivers 10 drops per mL. How many drops per minute should fall into the drip chamber?
20 to 21
A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?
42 drops/minute
A nurse caring for a client in active labor notes right sacrum anterior (RSA) position. Which location should the nurse anticipate to hear the fetal heart sound loudest?
Above the umbilicus at the right upper quadrant.
Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
An increased sense of rectal pressure
A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?
Ask the client about her most recent blood glucose levels.
During the active phase of the first stage of labor, a client undergoes an amniotomy. Which action should the nurse take to prevent complications? Select all that apply.
Assess for cord prolapse postprocedure. Monitor fetal heart rate. Reposition the client to the left side. Monitor blood pressure.
A client has received dinoprostone to help ripen her cervix. What should the nurse do to determine effectiveness of the drug?
Assess for ripening and softening of the cervix.
Which care intervention is appropriate for the fourth stage of labor?
Assessing lochia and the location and consistency of the fundus
A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best?
Assisting the client to ambulate in the room
The nurse is caring for a 28-year-old primigravida who is reporting severe back labor. Which nursing intervention is most effective in improving the comfort of the client?
Back massage with sacral pressure
A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.
Check vital signs.Check the fundal height.Notify the RN.
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?
Collaborate with the physician to make a referral to social services.
An actively laboring client who is 6 cm dilated and who attended natural childbirth classes asks the nurse for pain medication. What is the most appropriate action by the nurse?
Contact the health care provider for pain medication.
A diabetic client in labor tells the nurse she has been feeling nauseous since her labor started and did not take her insulin even after eating some soup and crackers. One hour later, she reports increased nausea and feeling flushed. The nurse notes a fruity odor to her breath. What do these findings suggest?
Diabetic ketoacidosis
The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.
A client who is induced at 40 weeks' gestation with oxytocin drip is expressing fear and anxiety about the induced labor. Which interventions should the nurse implement? Select all that apply.
Establish trust with the client. Explore the client's coping behaviors Keep client informed about progress and procedures.
The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?
Influence of the extended family
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time?
Instruct the husband on touch, massage, and breathing patterns.
Which intervention should be included in the safety plan for the maternal- infant unit?
Making sure that the spouse or significant other wears an identification band
A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next?
Massage the fundus.
A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?
Massage the fundus.
The nurse is caring for a client whose labor was induced with oxytocin. Which interventions will reduce adverse effects associated with oxytocin administration during labor? Select all that apply.
Monitor the frequency, intensity, and duration of uterine contractions. Monitor urine output. Monitor blood pressure.
A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action?
Notify the physician that the partner has been waiting to discuss the mother's condition.
A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?
Prepare the client and partner for a cesarean birth as soon as possible.
A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol?
Stop the visitor, and ask for identification.
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress?
blood pressure of 146/94 mm Hg
A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?
fetal heart rate of 80 beats/minute
A gravida 3 client reveals that she gave birth to her first child vaginally and her second child by cesarean birth due to a complete placenta previa. The client agrees to attempt a vaginal birth after cesarean (VBAC) and presents at the local hospital in early labor, 3 to 4 cm dilated, 80% effaced, and at +1 station. The nurse anticipates the possibility of VBAC based on which type of incision noted in the record?
lower uterine segment transverse incision
A client at 36-weeks' gestation is admitted to the hospital with placenta previa. The licensed practical nurse (LPN) is reviewing the client's medical record. Which findings would the LPN interpret as supporting this condition? Select all that apply.
normal fundal height vaginal bleeding
A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to
perinatologist
A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?
physician
A client has given birth vaginally several minutes ago. The nurse notes blood gushing from the vagina, the umbilical cord lengthening, and a globe-shaped uterus. The nurse should monitor the client closely for which condition?
placental separation
A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?
postpartum hemorrhage
A client is admitted to the labor unit in early labor. The nurse would encourage the client to assume which position to promote tissue perfusion?
side-lying
A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?
stimulates labor and prevents hemorrhage
A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to
the social worker on call.
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for:
uterine inversion.
