NCLEX 6th Edition/ Maternal-NB/ Intrapartum

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated?

8 to 10 cm

A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure?

A cesarean birth

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?

A manual pelvic examination

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor?

Administer oxygen as prescribed.

The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond?

Administer oxygen via face mask to the mother.

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem?

Anxiety and fear

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest

The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time?

Continue monitoring the client because the data reflect acceptable progress.

The nurse is caring for a client in labor. The nurse reviews the health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. The nurse understands that the action of this medication is to have which effect?

Decrease pain.

The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?

Decreased periods of uterine relaxation between contractions

The nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which condition becomes apparent?

Decreased periods of uterine relaxation between contractions

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Determine the fetal heart rate.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Determine the parents' desires for contact with the newborn.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns.

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?

Fear about what is happening

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?

Fear of losing control

Which would be the appropriate method to use to deliver the placenta after a precipitate delivery?

Gently guide the placenta out after a spontaneous separation.

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

Have the client empty her bladder.

A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicates to the nurse the presence of concealed bleeding?

Increase in fundal height

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?

Increased efficiency of contractions

Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal?

It is pale, straw-colored with flecks of vernix.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?

Keep the client in a side-lying position.

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?

Lateral Sims'

A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position?

Left lateral

A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse include in the plan of care?

Maintain complete bed rest, monitor IV fluid intake, and monitor the fetal heart rate.

The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which as least likely necessary for the care of this client?

Measuring the fundal height

The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?

Minus (-) 1 station

The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?

Monitor the fetal heart rate.

The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?

Notify the registered nurse (RN).

The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which action at this time?

Notify the registered nurse of a possible maternal infection.

During the intrapartum period, the nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which result?

Prevent dehydration and hypoxemia.

The nurse is assigned to assist in caring for a client in labor. The nurse would determine that which sign/symptom would least likely indicate dystocia?

Progressive changes in the cervix

The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?

Provide pain relief measures.

Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta?

Pull gently on the cord as the mother bears down.

A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?

Report the time of last food intake to the health care provider.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Side-lying

The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which?

Signs of shock

The nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding which is the nurse's priority action?

Stop the oxytocin infusion.

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?

When was the last time the client ate or drank?

The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.

-The fetus is in the breech position. -Lesions are present on the perineum. -The fetus is not settled into the pelvis.

A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply

-Uterus soft to palpation -Bright red vaginal bleeding

The nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is in which position?

1 cm above the ischial spines

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document that the FHR is normal if which result is noted?

150 beats per minute

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which?

1 cm above the ischial spines

The nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.

-Signs of fetal distress -High level of maternal anxiety -Failure of the fetus to descend

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client?

"Leopold's maneuvers are used to determine fetal position."

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

"Tell me what you mean when you say that your baby has moved."

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?

"What an efficient way to record my baby's heart rate."

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms would indicate that the client's bleeding is caused by placenta previa? Select all that apply.

-Bright red vaginal bleeding -Lack of uterine contractions

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply.

-Bright red vaginal bleeding -Soft, relaxed, nontender uterus

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?

A change in the uterine contour

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?

Administering oxygen via face mask

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor which criteria?

All vital signs, especially heart rate and blood pressure

During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which is the primary purpose of this action?

Assist in preventing dehydration and hypoxemia.

A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort?

Assist the client to ambulate in the room

The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which?

Characteristics of contractions

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.

-Constant fever of 101° F -Persistent pelvic heaviness -Foul-smelling vaginal discharge

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?

Contraction stress test

A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete rupture occurs?

Decreasing blood pressure

The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?

Determine the fetal heart rate.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, which action should the nurse take initially?

Determine the maternal and fetal vital signs.

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse should include which in the plan of care?

Maintain continuous electronic fetal monitoring.

The nurse is assigned to care for a client experiencing dystocia. Which would be the highest priority in planning care?

Monitoring for changes in the physical and emotional condition of the mother and fetus

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?

Oozing from injection sites

A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate?

Prepare the client for a cesarean delivery.

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal?

Prevent dehydration and hypoxemia.

If a precipitate delivery is imminent, which would be the appropriate nursing action?

Put on sterile gloves, and gently guide the baby's head and shoulders out.

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock?

Restlessness and agitation

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse would place the client at risk for uterine rupture?

Shoulder dystocia

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position?

Supine with a wedge under the right hip

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?

The client feels hopeless about the situation.

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

White blood cell count of 35,000 cells/mm3

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problems should the nurse expect to note on the plan of care?

Anxiety related to a slow progress of labor

The nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

Changes in the shape of the uterus

A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?

Check the fetal heart rate.

The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take?

Continue to assess vital signs and fetal heart rate the same as before the nerve block.

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?

Effleurage is light stroking of the abdomen to facilitate relaxation during labor.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?

Encourage the client to discuss her concerns and desires regarding anesthesia options.

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?

Fetal tachycardia

For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes lasting 60 to 70 seconds and strong to palpation. She is dilated 2 cm and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?

Hypertonic

The nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?

Pain level is "4" while a progressive labor pattern continues.

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition?

Placental separation

The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose?

Reduce the risk of injuring the bladder during the surgery.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse?

Respirations of 10 breaths per minute

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?

Supine position with a wedge under the right hip

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?

To regain her breathing pattern

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?

Uterine tenderness on palpation

When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply.

-One vein -Two arteries

The advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply.

-Ease of administration -Absence of fetal hypoxia -Immediate onset of anesthesia

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply.

-Encourage frequent urination. -Continue maternal and fetal assessments. -Review breathing and relaxation techniques.

The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?

Continue to monitor the client.

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?

Change in uterine shape

The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?

Newborn

The nurse should prepare to give a prescribed oxytocic medication after delivery of which?

Placenta

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time?

Rest between contractions

The nurse is caring for a woman in the labor room. The health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?

Resting interval of 50 seconds

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn.