Intrapartum

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory 2. Ischial spines 3. Cervix 4. Symphysis pubis

2. station is asses by palpating the ischial spines

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply 1. Hypnotic suggestion 2. Rhythmic chanting 3. Muscle relaxation 4. Pelvic rocking 5. Abdominal massage

3, 4, and 5 are correct

The Lamaze childbirth educator is teaching a class of pregnant couples the berthing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow 2. Take rhythmic, shallow breaths 3. Push done with an open glottis 4. Do slow chest breathing

3. Open glottal pushing is used during stage 2 of labor

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultations". To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction 2. For 10 minutes every half hour 3. Only during the peak of contractions 4. For 1 minute immediately after contractions

4. Intermittent auscultation should be performed for 1 full minute after contractions end

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing 2. Rapid, deep breathing 3. Grunting and pushing with contractions 4. Slow chest breathing

4. Most women find slow chest breathing effective during the latent phase

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply 1. Bulging perineum 2. Increased bloody show 3. Spontaneous rupture of the membranes 4. Uncontrollable urge to push 5. Inability to breathe through contractions

1, 2, and 4

On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent 4. External rotation is complete

1. Descent is progressing well. The presenting part is 3 cm below the ischial spines

In addition to breathing with contractions, the nurse should encourage women in first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position 2. Performing effleurage 3. Practicing kegal exercises 4. Pushing with each contraction

2. Effleurage is a light massage that can soothe the mother during labor

A Clint who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure 2. Have the woman breathe into a bag 3. Turn the woman onto her side 4. Check the fetal heart rate

2. The client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to be move bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan 2. Evaluate the progress of labor 3. Notify the physician 4. Encourage the patient to push

2. The nurse should first assess the progress of the labor to see if the client has moved into the second stage of labor

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? 1. Awaken the woman and remind her to push 2. Cover the woman's perineum with a sheet 3. Assess the woman's blood pressure 4. Administer oxygen to the woman via face mask

2. The woman's privacy should be maintained while she is resting

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA - 1 station 2. LSP - 1 station 3. LMP +1 station 3. LSA +1 station

2. the LSP position is the correct answer

A client is complaining of serve back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing 2. Encourage mother to have an epidural 3. Provide direct sacral pressure 4. Move the woman to a hydrotherapy tub

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.

The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercise during labor refrain from yelling 2. Breathing and relaxation exercises are less exhausting than crying and moaning 3. Knowledge learned at childbirth education classes helps to break the fear-tension- pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn

3. Some of the techniques learned in childbirth education classes are meant to break the fear-tension- pain cycle

When performing Leopold maneuvers, the nurse notes the the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. Left upper quadrant 2. Rigt upper quadrant 3. Left lower quadrant 4. Right lower quadrant

3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal examinations and blood tests 2. Focusing the discussion on baby care rather than on labor and delivery 3. Utilizing visual aids like movies and posters during classes 4. Having the classes at a location other than high school to reduce their embarrassment

3. Using visual aids can help to foster learning in teens as well as adults

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal heal is seen at the vaginal Introits. The nurse concluded the client is now: 1. 9cm dilated, 70% effaced , and +2 station 2. 9 cm dilated, 80% effaced, and +3 station 3. 10 cm dilated, 90% effaced, and +3 station 4. 10 cm dilated, 100% effaced, and +5 station

4. The cervix is fully dilated and fully effaced and the baby is enough to be seen through the vaginal introitus

A woman who states that she "thinks" she is in labor enters the labor suit. Which of the following assessments will provide the nurse with the most valuable information regarding the clients labor status? 1. Leopold maneuvers 2. Fundal contractility 3. Fetal heart assessment 4. Vaginal examination

4. Vaginal examination will provide the nurse with the nest information about the status of labor.

A woman had just arrived at the labor and delivery suite. To report the clients status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply 1. Fetal heart rate 2. Contraction pattern 3. Urinalysis 4. Vital signs 5. Biophysical profile

1, 2 and 4

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse nots from the woman's prenatal record before proceeding with the physical assessment? Select all that apply 1. Weight gain 2. Ethnicity and religion 3. Age 4. Type of insurance 5. Gravidity and parity

1, 2, 3, and 5

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low risk woman, G1 P0000? Select all that apply 1. After vaginal examinations 2. Before administration of analgesics 3. Periodically at the end of a contraction 4. Every ten minutes 5. Before ambulation

1, 2, 3, and 5

While evaluating the fetal heart monitor tracing on the client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions 2. The maternal blood pressure 3. The gestational age of the fetus 4. The placement of the fetal heart electrode in relation to the fetal position

1. The relationship between the decelerations and the contractions will determine the type of deceleration pattern

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1.Mentum anterior. 2.Sacrum posterior. 3.Occiput posterior. 4.Scapula anterior.

3. When a fetus is in the occupy posterior position, a mother frequently complain of server back pain.

The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA) 2. Left scrap posterior (LSP) 3. Right mentum anterior (RMA) 4. Right sacral posterior (RSP)

1. LOA

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 BPM. What should the nurse do? 1. Providing caring labor support 2. Administer oxygen via face mask 3. Change the clients position 4. Speed up the clients intravenous

1. The tracing is showing normal fetal heart tracing. No intervention is needed

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the follow interventions should the nurse perform first? 1. Encourage the women to have an epidural 2. Encourage the woman to accept intravenous analgesia 3. Encourage the woman to change her position 4. Encourage the woman to perform the next level breathing

4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathings appropriate at this time.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the follow actions by the nurse is appropriate? 1. Inform the mother that the rate is normal 2. Reassess in 5 minutes to verify the results 3. Immediately report the rate to the healthcare practitioner 4. Place the client on her left side and apply oxygen by face mask

1. This is the correct response

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client has poor childbirth education prior to labor 2. The client is exhibiting an expected behavior for labor 3. The client is becoming hypoxic and hypercapnia 4. The client needs her alpha-fetoprotein levels checked

2. The woman is showing expected sings of the active phase of labor

While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of he following is a reasonable conclusion by the nurse? 1. The fetal position is transverse 2. The fetal presentation is vertex 3. The fetal Liw is vertical 4. The fetal attitude is flexed

3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical