Maternity Passpoint 2

The nurse is caring for a client in labor who has tested positive for gonorrhea. Which will the nurse include in the client's plan of care?

Administer erythromycin eye drops to the infant after birth.

A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client?

Assess maternal contraction and fetal heart rate pattern.

While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, "I think my water just broke." What should the nurse do first?

Assess the fetal heart rate pattern.

A client with diabetes mellitus gives birth to a 9-lb, 10-oz (4,375 g) neonate at 38 weeks. What is the nurse's priority action after the stabilization of the neonate?

Assess the neonate's blood glucose level.

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply.

Change the client's position. Contact the healthcare provider. Administer oxygen to the client

A laboring client on oxytocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings which of the following would be the best action for the nurse?

Discontinue the oxytocin if the uterus does not relax between uterine contractions.

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

A 32-year-old primigravida at 39 weeks' gestation is admitted to the hospital in active labor. While the nurse performs Leopold's maneuvers, the client asks why these maneuvers are being done. The nurse explains that the major purpose of these maneuvers is to determine which factor?

Fetal Presentation

Which nursing action is required before a client in labor receives an epidural anesthetic?

Give a fluid bolus

A client who is 5 cm dilated reports that she has the urge to push. Which is the appropriate response by the nurse?

Have client blow out breath to keep from pushing.

What should the nurse include in the plan of care for a client with diabetes who is in labor?

Monitor blood glucose levels every hour.

A nurse needs to obtain a good monitor tracing on a client in labor. The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first?

Reposition the client to her left side.

Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?

The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.

While caring for a client who has just given vaginal birth to a neonate, the nurse is monitoring for signs of placental separation. What signs indicate that the placenta has separated? Select all that apply.

change in shape of the uterus lengthening of the umbilical cord sudden gush of vaginal blood

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?

duration, frequency, and intensity

A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?

fetal heart rate of 80 beats/minute

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion?

fetal heart rate variability within 5 to 10 beats/minute

The nurse is caring for a client in labor. How would the nurse report the frequency of each contraction?

measuring the length of time from the start of one contraction to the start of the next

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?

umbilical cord prolapse

This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins at the end of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated

with uteroplacental insufficiency, shock, or fetal metabolic acidosis.

The nurse has administered promethazine intravenously to a client in active labor. The drug has had the desired effect when the nurse notes which finding?

decreased nausea and vomiting

The nurse is discussing pain relief methods for a pregnant first-time mother. The discussion should include which labor support methods? Select all that apply.

effleurage guided imagery pattern-paced breathing progressive relaxation

The primary health care provider (HCP) prescribes betamethasone for a 34-year-old multigravid client at 32 weeks' gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks' gestation. The nurse explains that this drug is given for which reason?

to enhance fetal lung maturity

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?

latent phase