NUR 308 Chapter 14

Which action is a PRIORITY when caring for a woman during fourth stage of labor? A. assessing the uterine funds B. offering fluids as indicated C. encouraging the woman to void D. assisting w perineal care

A. assessing the uterine funds

A client's membranes spontaneously ruptured as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? A. check FHR B. perform vaginal exam C. notify HCP immediately D. change linen saver pad

A. check FHR

A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant woman. Which statement indicates the teaching was successful? A. we can get up and walk around after receiving combined spinal epidural analgesia B. higher anesthetic doses are need for pt controlled epidural analgesia C. pudenal nerve block is highly effect for pain relief in the first stage of labor D. local infiltration block using lidocaine is an appropriate method for controlling contraction pain

A. we can get up and walk around after receiving combined spinal epidural analgesia

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2cm above the ischial spines. The nurse documents this finding as: A. +2 station B. 0 station C. -2 station D. crowning

C. -2 station

A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next? A. suctioning of mouth and nose B. clamping of the umbilical cord C. checking for cord around the neck D. drying of the newborn

C. checking for cord around the neck

A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse MOST likely use when explaining this measure? A. This technique focuses on manipulating body tissues B. the technique requires focusing on a specific stimulus C. this technique involves light stroking of the abdomen w breathing

C. this technique involves light stroking of the abdomen w breathing

A client states " I think my water broke! I felt this gush of fluid b/w my legs." The nurse tests the fluid w/in nitrazine paper and confirms membranes rupture if the swab turns: A. yellow B. olive green C. pink D. blue

D. blue

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: a. normal b. possible infection c. meconium passage d. transient fetal hypoxia

b. possible infection

When palpating the funds during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A. intense B. strong C. moderate D. mild

C. moderate

When planning the care of a woman in the latent phase of labor, the nurse would anticipate assessing the fetal HR at which interval? A. every 30 to 60 mins B. every 60 to 90 mins C. every 15 to 30 mins D. every 10 to 15 mins

A. every 30 to 60 mins

A nurse is performing Lepold maneuvers on a pregnant woman. The nurse determines which information w the first maneuver? A. fetal presentation B. fetal position C. fetal attitude D. fetal flexion

A. fetal presentation

A nurse palates a woman's funds to determine contraction intensity. What would be most appropriate for the nurse to use for palpation? A. finger pads B. palm of the hand C. finger tips D. back of the hand

A. finger pads

A pregnant woman is discussing nonpharmocologic pain control measure w the nurse in the anctipcation of the labor. After discussing the various breathing patterns that can be used, the woman decides to use slow paced breathing. Which instruction would the nurse provide to the woman abt this technique? A. inhale through your nose and exhale through pursed lips B. inhale and. exhale through your mouth about 4 times in 5 seconds C. forcefully exhale every so often after inhaling and exhaling your mouth D. take a cleansing breath before nut not after each contraction

A. inhale through your nose and exhale through pursed lips

A nurse is reading a journal article abt the various medications used for pain relief during labor. Which drug would the nurse note as producing amnesia but no analgesia ? A. midazolam B. prochlorperazine C. fentanyl D. meperidine

A. midazolam

A woman in labor received an opiod close to the time of birth. The nurse would assess the newborn for which effect? A. respiratory depression B. urinary retention C. abdominal distention D. hyperreflexia

A. respiratory depression

A nurse is conducting a class for a group of nurses who are newly hired for labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group indentifies which findings as indicating normal fetal acid base status? select all that apply. A. sinusoidal pattern B. recurrent variable decelerations C. fetal bradycardia D. absence of later decelerations E. moderate baseline variability

A. sinusoidal pattern B. recurrent variable decelerations C. fetal bradycardia

Which position would be MOST appropriate for the nurse to suggest as a comfort measure to woman who is in the first stage of labor? Select all that apply A. walking w partner support B. straddling w forward leaning over a chair C. closed knee- chest position D. rocking back and forth w foot on chair E. supine w legs raised at 90 degrees

A. walking w partner support B. straddling w forward leaning over a chair D. rocking back and forth w foot on chair

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV positive. Which action would the nurse expect to include when developing a plan of care for this woman? Select all that apply. A. administrating penicillin G at onset of labor B. avoiding scalp electrodes for fetal monitoring C. refraining from obtaining fetal scalp blood for pH testing D. administering antretrovial therapy at onset of labor E. electing for the use of forceps assisted birth

B. avoiding scalp electrodes for fetal monitoring C. refraining from obtaining fetal scalp blood for pH testing D. administering antretrovial therapy at onset of labor

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? A. intact membranes B. cervical dilation of 2 cm or more C. floating presenting fetal part D. neonatologist to insert the electrode

B. cervical dilation of 2 cm or more

Which suggestion by the nurse abt pushing would be most appropriate to a woman in the second stage of labor? A. lying flat w head elevated on2 pillows making pushing easier B. choose whatever method you feel comfortable w for pushing C. let me help you decide when it is time to start pushing D. bear down like your having a bowel movement w every contraction

B. choose whatever method you feel comfortable w for pushing

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of physical assessment? Select all that apply. A. current pregnancy hx B. fundal height measurement C. support system D. estimated date of birth E . membrane status F. contraction pattern

B. fundal height measurement E. membrane status F. contraction pattern

A nurse is assessing a woman after birth and notes a second degree laceration. The nurse interprets this as indicating that the tear extends through which area? A. skin B. muscles of perineal body C. anal sphincter anterior rectal wall

B. muscles of perineal body

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching? A. this type of monitoring if most accurate method for our baby B. unfortunately Im going to have to stay quite still in bed while it is in place C. this type of monitoring can only be used after my membranes rupture D. you'll be inserting a special electrode into my baby's scalp

B. unfortunately Im going to have to stay quite still in bed while it is in place

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U shape. The nurse interprets these changes as reflecting which type of deceleration? A. early decelerations B. variable decerleations C. prolong decelerations D. later decelerations

B. variable decerleations

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the clients body to record FHR? A. over the uterine fundus where the contractions are most intense B. above the umbilicus toward the right side of the diaphragm C. b/w the umbilicus and symphysis pubis D. b/w the xiphiod process and umbilicus

C. b/w the umbilicus and symphysis pubis

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds? A. @ level of woman umbilicus B. in the area above the women umbilicus C. in the woman lower abdomen quadrant D. at the upper outer quadrant of the woman abdomen

C. in the woman lower abdomen quadrant

A woman in labor received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A. butorphanol B. fentanyl C. naloxone D. promethazine

C. naloxone

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? A. check pH to ensure the fluid is ammniotic fluid B. prepare to administer an antibiotic C. notify HCP abt possible meconium D. check maternal HR

C. notify HCP abt possible meconium

a nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. boggy soft uterus B. uterus becoming discoid shape C. sudden gush of dark blood from the vagina D. shortening of the umbilical cord

C. sudden gush of dark blood from the vagina

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A. The warmth and buoyancy of the water has a nice relaxing effect B. I can stay in the bath as long as I feel comfortable C. my cervix should be dilated more than 5 cm before I try using this method D. the temperature of the water should be at least 105 (40.5)

D. the temperature of the water should be at least 105 (40.5)