OB Exam 2

A client states that her water broke 2 hours ago. What findings should the nurse identify as indications of normal labor? Select all that apply. 1. Protein of +1 in urine 2. Maternal pulse of 160 3. Blood pressure of 120/80 4. Odorless, clear fluid on underwear 5. Fetal heart rate (FHR) of 130 with average variability

3, 4 and 5

The nurse is caring for a high-risk client in the second stage of labor. After which actions should the nurse assess the fetal heart rate? Select all that apply. 1. Vaginal examination 2. Urinary catheterization 3. Ingestion of clear liquids 4. Administration of pain medication 5. Change in oxytocin administration

1, 2, 4, and 5

When caring for a client with oligohydramnios, on what should the nurse focus? Select all that apply. 1. Induction is typically scheduled. 2. Early decelerations are more likely. 3. Fetal pulmonary hypoplasia can develop. 4. There is an increased risk of cord compression. 5. Labor progress is often more rapid than average.

1, 2, 3, and 4

The nurse is explaining Leopold maneuvers to a client who is in the early stage of labor. What should the nurse explain as being the purpose of the second maneuver? 1. Locate the fetal back 2. Identify the descent of the presenting part into the pelvis 3. Determine if the pelvic inlet contains the head or buttocks 4. Determine if the fetal head or buttocks occupies the uterine fundus

1

The nurse is observing a student provide care to a client who is in early labor. Which student actions should be corrected? 1. Applying a fetal heart monitor followed by an explanation of the reason for its use 2. Upon entering the room, speaking with the client prior to looking at the fetal heart monitor 3. Using layman's terms to provide the client with an explanation of the reason for electronic fetal monitoring 4. Incorporating cues that arise from intuition or from observations of the client and family as opposed to focusing on the fetal heart monitor

1

A client at 40 weeks' gestation is being considered for cervical ripening. Which criteria should the nurse use to determine the client's success for induction? Select all that apply. 1. Position 2. Effacement 3. Consistency 4. Fetal heart rate 5. Cervical dilatation

1, 2, 3, and 5

The newborn of a client who received nalbuphine hydrochloride (Nubain) for pain control was born less than an hour after the medication was given and is exhibiting signs of respiratory depression. Which medication should the nurse prepare to administer to the newborn? 1. Naloxone (Narcan) 2. Fentanyl (Sublimaze) 3. Pentobarbital (Nembutal) 4. Butorphanol tartrate (Stadol)

1

A client in labor with cervical dilation of 9 cm is experiencing contractions every 2 minutes that are 60 to 90 seconds in duration and is complaining of excruciating rectal pressure. How should the nurse interpret this complaint? 1. The client's complaint is congruent with her current stage of labor. 2. The client's complaint may indicate the need for delivery via cesarean section. 3. Based upon the client's complaint, she is experiencing the active phase of labor. 4. The client's complaint is consistent with placental separation, which is normal for her current stage of labor.

1

A healthy 18-year-old client who is at 40 weeks' gestation experiences vaginal expulsion of stringy mucus followed by blood-tinged secretions unaccompanied by discomfort or any other changes. Based upon these findings, what is most likely to occur within the next 24 to 48 hours? 1. Onset of labor 2. Cesarean section 3. Chorioamnionitis 4. Spontaneous abortion

1

The blood pressure of a client receiving continuous epidural anesthesia for labor has changed from 132/78 mmHg to 78/42 mmHg. What action should the nurse perform first? 1. Administer oxygen. 2. Administer ephedrine 5 to 10 mg intravenously. 3. Verify the client is positioned to promote left uterine displacement. 4. Increase the flow rate of infusion of intravenous crystalloid solution.

1

The client in labor with meconium-stained amniotic fluid asks why the fetal monitor is necessary because the belt is uncomfortable. What should the nurse explain about monitoring? 1. "It helps us to see how the baby is tolerating labor." 2. "It can be removed, and oxygen can be given instead." 3. "It is necessary so we can see how your labor is progressing." 4. "It will prevent complications from the meconium in your fluid."

1

The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective? 1. "A vaginal examination is performed if delivery appears to be imminent." 2. "Her prenatal record is reviewed for indications of domestic abuse." 3. "She will be positioned supine to facilitate a normal blood pressure." 4. "A urine specimen is obtained by catheter to check for protein and ketones."

1

The nurse is preparing to monitor the fetal heart rate (FHR) of a pregnant client. What should the nurse explain to a nursing student as being the baseline (BL) of this heart rate? 1. "The baseline FHR excludes periods of marked variability." 2. "Normal baseline FHR ranges from 100 to 180 beats per minute." 3. "The baseline FHR should include periodic or episodic changes in FHR." 4. "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute."

1

Which pattern, if seen on an electronic fetal monitoring strip, should the nurse explain to a client in labor as being a change in the baseline fetal heart rate? 1. Tachycardia 2. Acceleration 3. Late deceleration 4. Sinusoidal pattern

1

The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first? 1. Facilitate a maternal left lateral position. 2. Alert the healthcare provider of the fetal status. 3. Decrease the rate of infusion of intravenous fluids. 4. Administer oxygen to the client at 4 L per minute via nasal cannula.

1 (In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow. While the attending healthcare provider should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct client care. Initially, the mother should be placed in the left lateral position. Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids. Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 L per minute via face mask.)

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which pain response should the nurse identify as most likely to impede progress in labor? 1. Muscle tension 2. Increased pulse 3. Increased respirations 4. Elevated blood pressure

1 (Muscle tension can impede labor progress by increased oxygen and calorie consumption and by creating a mechanical obstruction that the uterine contractions must overcome to achieve labor progress.)

A client experiencing contractions every 8 to 20 minutes that last 20 to 30 seconds requests pain medication. What should the nurse state as the effect of analgesics given at this time? 1. Prolonged labor 2. Maternal hypotension 3. Fetal respiratory depression 4. Decreased analgesic effectiveness at the end of labor

1 (Pain medication given before labor becomes established is likely to prolong the labor process.)

A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action? 1. Assess blood pressure and check for proteinuria. 2. Obtain a Social Services referral to discuss adoption. 3. Determine who might be the father of the baby for paternity testing. 4. Ask the client what kind of birthing experience she would like to have.

1 (Preeclampsia is more common among adolescents than in young adults, and it is potentially life threatening to both the mother and fetus. This assessment is the highest priority. Social services would not be appropriate during active labor. Wait until after the birth.)

The student nurse is performing Leopold maneuvers on a client in labor. For which action should the staff nurse intervene? 1. After determining where the back is located, the cervix is assessed. 2. The upper portion of the uterus is palpated, and then the middle section. 3. Following voiding, the client's abdomen is palpated from top to bottom. 4. The client is assisted into the supine position, and the position of the fetus is assessed.

1 (The cervical examination is not a part of Leopold maneuvers; abdominal palpation is the only technique used for the Leopold maneuver. This is correct order of the first and second Leopold maneuvers. The client is instructed to void prior to beginning Leopold maneuvers to facilitate comfort; Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix. Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation.)

A client at 38 weeks' gestation is diagnosed with oligohydramnios. Which statement indicates that teaching has been effective? 1. "When I go into labor, I should come to the hospital right away." 2. "My gestational diabetes may have caused this problem to develop." 3. "Women with this condition usually go into labor after their due date." 4. "This problem is common and will likely occur with my next pregnancy."

1 (The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the client with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop.)

A client is entering the end of the second stage of labor. What should the nurse expect to assess in this client? Select all that apply. 1. Bulging perineum 2. Parting of the labia 3. Crowning of the fetus 4. Increasing bloody show 5. Increasing rectal pressure

1, 2, 3, and 4 (increased rectal pressure is part of the transitional phase)

The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4. 30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz

1 (Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern. Hypertension does not impact labor pattern; this client has no risk factors for either hypertonic or hypotonic labor pattern development. Although this client is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this client has no risk factors for an abnormal labor pattern. This client has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development.)

The nurse explains to a client in labor that the fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement about the most important part of fetal heart monitoring indicates that the client understands the nurse's teaching? 1. "Presence of variability" 2. "Depth of decelerations" 3. "Fetal heart rate baseline" 4. "Absence of variable decelerations"

1 (Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system. The depth of decelerations does not indicate central nervous system function. The fetal heart rate baseline does not indicate central nervous system function. Variable decelerations indicate cord compression.)

A client scheduled for elective cesarean birth in 4 hours asks for a sip of coffee with creamer. How should the nurse respond? 1. "You can drink black coffee." 2. "You may have coffee with creamer." 3. "You are only allowed to drink water right now." 4. "Since you are having surgery today, you're not allowed to have anything to eat or drink."

1 (clear fluids only)

A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed? 1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collar bone broken."

1 (hypoglycemia, not hyperglycemia is risk with macrosomia)

The nurse is caring for a 13-year-old client who is in labor. What actions should the nurse take to support this client's needs? Select all that apply. 1. Provide simple and concrete explanations. 2. Stay with the client during the labor process. 3. Provide soothing encouragement during the transition phase. 4. Provide positive reinforcement with a nonjudgmental manner. 5. Remain calm and provide clear directions during the second stage.

1, 2, 3, 5

A pregnant client is scheduled for a transabdominal cerclage. What teaching information should the nurse prepare for this client? Select all that apply. 1. Cesarean section birth 2. Preoperative laparotomy 3. Potential for hydramnios 4. Risk for abruptio placentae 5. Premature rupture of membranes

1 and 2

A client in labor needs an emergency cesarean section. What should the nurse include when preparing this client for rapid induction of labor? Select all that apply. 1. Place a wedge under the right hip. 2. Insert an indwelling urinary catheter. 3. Insert an intravenous infusion catheter. 4. Provide a bolus of 1 L of intravenous fluid. 5. Preoxygenate with 3 to 5 minutes of 100% oxygen.

1, 2, 3, and 5 (option 4 is for epidural, not for emergency c section)

A client is recovering from general anesthesia after an emergency cesarean birth. What actions should the nurse take when providing care to this client? Select all that apply. 1. Position on the left side. 2. Observe urine for hematuria. 3. Assess level of anesthesia every 15 minutes. 4. Evaluate perineal pad every 15 minutes for 1 hour. 5. Gently palpate the fundus with vital signs assessment.

1, 2, 4, and 5

A client in the beginning stages of labor asks the nurse if the labor process will hurt the baby. What should the nurse explain to the client about the fetus's response to labor? Select all that apply. 1. The baby's heart rate will change. 2. The baby feels no pain or sensations. 3. The baby is sensitive to light and sounds. 4. The baby's oxygen level drops about 10%. 5. The blood pressure protects the baby during labor.

1, 2, 4, and 5 (Early fetal heart rate decelerations can occur with intracranial pressures of 40 to 55 mmHg, as the head pushes against the cervix. The fetus is experiencing labor as the woman labors. Beginning at about 37 or 38 weeks' gestation, the fetus is able to experience sensations of light, sound, and touch. Blood flow is decreased to the fetus at the peak of each contraction and fetal oxygen saturation drops about 10%. Fetal blood pressure protects the normal fetus during the anoxic periods caused by the contracting uterus during labor.)

The spouse is concerned that the client in labor will be hungry since the last time any food was eaten was several hours ago. What should the nurse explain as effects of the labor process on the client's gastrointestinal system? Select all that apply. 1. Reduced gastric motility 2. Increased gastric volume 3. Increased gastric motility 4. Reduced absorption of food 5. Prolonged gastric emptying time

1, 2, 4, and 5 (gastric motility would decrease not increase)

The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply. 1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations

1, 2, 5

A client at 40 weeks' gestation is prescribed dinoprostone (Cervidil) for cervical ripening. What should the nurse include when teaching the client about this medication? Select all that apply. 1. Cramping can occur. 2. Uterine irritability is expected. 3. Membrane rupture is a sign of labor. 4. Leakage of the gel should be reported. 5. Strong regular contractions are expected.

1, 2, and 3

A pregnant client diagnosed with hydramnios asks for more information about this health problem. What should the nurse include in this teaching? Select all that apply. 1. The exact cause is unknown. 2. It can cause shortness of breath and edema. 3. It can be associated with maternal diabetes. 4. It occurs in large-for-gestational-age infants. 5. It is associated with renal malformation or dysfunction.

1, 2, and 3

The nurse is reviewing the medical history of a pregnant client being considered for cervical ripening. Which data indicate that the order for misoprostol (Cytotec) should be reconsidered? Select all that apply. 1. Current fetal heart rate is tachycardic. 2. Client had one cesarean live birth 3 years ago. 3. Uterine contractions are occurring every 2 minutes. 4. Client has 2+ pedal edema and elevated blood pressure. 5. There is a history of placenta previa with one previous pregnancy.

1, 2, and 3 (Absolute contraindications for the use of misoprostol include fetal tachycardia. Absolute contraindications for the use of misoprostol include a history of previous cesarean birth. Absolute contraindications for the use of misoprostol include the presence of uterine contractions 3 times in 10 minutes.)

A client in labor received a dose of meperidine (Demerol) for pain control. Which assessment findings should the nurse suspect are adverse effects of this medication? Select all that apply. 1. Nausea 2. Pruritus 3. Sedation 4. Bradycardia 5. Hypotension

1, 2, and 3 (Nausea is an adverse effect of meperidine. Pruritus is an adverse effect of meperidine. Sedation is an adverse effect of meperidine. Bradycardia is an adverse effect of fentanyl. Hypotension is an adverse effect of nalbuphine hydrochloride and fentanyl.)

The nurse is preparing a client in labor for an emergency cesarean section. Which medication should the nurse expect to be prescribed to prevent the effects of aspirated gastric contents? Select all that apply. 1. Famotidine (Pepcid) 2. Cimetidine (Tagamet) 3. Omeprazole (Prilosec) 4. Pantoprazole (Protonix) 5. Metoclopramide (Reglan)

1, 2, and 5

During an antenatal examination the nurse becomes concerned that the client is at high risk. What findings did the nurse use to make this clinical determination? Select all that apply. 1. Smokes one half pack per day of cigarettes 2. Employer provides maternal leave of absence 3. Is estranged from family and the baby's father 4. Loss of 3 lb since last examination 1 month ago 5. Treated for a sexually transmitted infection (STI) 2 months ago

1, 3, 4, and 5

The nurse is preparing to admit a pregnant client who is Muslim to the birthing center. What should the nurse keep in mind during the labor process? Select all that apply. 1. Have long-sleeved gowns available. 2. Offer warm fluids to sip during the labor process. 3. Ask the spouse for permission before examining the client. 4. Ensure female healthcare providers examine the client. 5. Provide the spouse with water to cleanse the newborn upon birth.

1, 3, 4, and 5

A multigravida client with suspected abruptio placentae is admitted in active labor. Which nursing diagnoses should the nurse identify as appropriate for this client? Select all that apply. 1. Anxiety related to concern for own safety 2. Ineffective Coping related to premature birth 3. Fluid Volume, Risk for Deficit, related to hypovolemia 4. Tissue Perfusion, Risk for Altered, related to blood loss 5. Knowledge Deficit related to lack of information about inherited genetic defects

1, 3, and 4

Which nursing action can prevent or detect common side effects of epidural anesthesia? Select all that apply. 1. Preloading the client with a rapid infusion of IV fluids 2. Continuing the client on oral fluids only to prevent hypotension 3. Assisting the client to empty the bladder before the anesthesia is started 4. Use of intermittent fetal heart rate (FHR) monitoring so the client can use the birthing ball 5. Monitoring the fetal heart rate (FHR) for late deceleration and decrease in rate

1, 3, and 5

The nurse suspects that a pregnant client is experiencing true labor. What did the nurse assess to make this clinical determination? Select all that apply. 1. Contractions increase in intensity. 2. Discomfort occurs in the abdomen. 3. Contractions occur at regular intervals. 4. Walking has no effect on the contractions. 5. Time between contractions gradually becomes shorter.

1, 3, and 5 (discomfort in abdomen could be false labor, walking should have an effect)

A client experiencing a difficult labor has a vacuum extraction birth. What is expected with this type of delivery? 1. The head is delivered after eight pulls during contractions. 2. The location of the vacuum is apparent on the fetal scalp after birth. 3. A bruise is present on the occiput that does not cross the suture line. 4. Positive pressure is applied by the vacuum extraction during contractions.

2

A client in labor is concerned about needing a cesarean section and being asleep during the birth of her baby. Which nursing response is most appropriate? 1. "Your anesthesia provider will require that you go to sleep for surgery." 2. "If a cesarean section is needed, that does not necessarily mean you will need to go to sleep for surgery." 3. "We will do our best to make sure you deliver vaginally, so you do not need to have a cesarean section." 4. "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly."

2

A client in labor who is requesting an epidural asks if the baby will be harmed. How should the nurse respond? 1. "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." 2. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." 3. "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." 4. "Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems."

2

A primiparous client is at 42 weeks' gestation. What order should the nurse question? 1. Begin non-stress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4. Schedule labor induction for tomorrow.

2

During the fourth stage of labor, the client's blood pressure (BP) is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What should the nurse do? 1. Massage the fundus. 2. Continue to monitor. 3. Turn the client onto her left side. 4. Place the bed in Trendelenburg position.

2

The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. What is the last assessment that the nurse should make before the client is draped for surgery? 1. Vaginal examination 2. Fetal heart tones 3. Maternal temperature 4. Maternal urine output

2

The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed? 1. "When you check my cervix, you will find out how thinned out it is." 2. "After you assess my pelvis, you will be able to tell when I will deliver." 3. "You are going to do a vaginal examination to see how far dilated my cervix is." 4. "The reason for a pelvic examination is to determine how low in the pelvis my baby is."

2

The risk management nurse is reviewing labor and delivery statistics over the last 2 years in an effort to decrease costs of maternity care. What finding contributes to increased healthcare costs in clients undergoing cesarean birth by request? 1. Prolonged anemia, requiring blood transfusions every few months 2. Increased abnormal placenta implantation in subsequent pregnancies 3. Decreased use of general anesthesia with greater use of epidural anesthesia 4. Coordination of career projects of both partners leading to increased income

2

Which client requires immediate intervention by the labor and delivery nurse? 1. Primipara in active labor with urine output of 100 mL/hour 2. Primipara that delivered 1 hour ago with white blood cells (WBCs) of 50,000 3. Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg 4. Multipara at 5 cm with a respiratory rate of 22 between contractions

2

The clinical nurse coordinator is reviewing the care of clients who undergo artificial rupture of membranes (AROM) by way of amniotomy with a group of nursing students. Which student statement indicates that the teaching has been effective? 1. "Amniotomy is contraindicated for use in labor augmentation." 2. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." 3. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'" 4. "In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed."

2 (Amniotomy is an accepted method of labor augmentation. Following .AROM, because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal examinations must be kept to a minimum to reduce the chance of introducing an infection. Women need to know that amniotic fluid is constantly produced because some women may worry that they will experience a "dry birth." In all cases, the .FHR is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared.)

A pregnant client is diagnosed with cervical insufficiency. How should the nurse expect this client to explain symptoms of this condition? 1. "I've been having contractions every 4 hours." 2. "I'm not having any pain and I do not feel any contractions." 3. "My cervical pain has gotten much worse over the past 2 days." 4. "I'm not having any pain, but my contractions are getting stronger."

2 (Cervical insufficiency is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix.)

A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate? 1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4. Oxytocin administration

2 (Cesarean section is the most likely course of action. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed.)

The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time? 1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid.

2 (Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.)

The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention? 1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4. Family refusing fetal autopsy

2 (Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level and indicates that the client is in DIC.)

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which participant statement indicates that additional information is needed? 1. "Because my hospital is so small and in a rural area, they will not let me attempt a VBAC." 2. "Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 3. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." 4. "My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down."

2 (Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classic vertical incisions on the uterus have a higher rate of rupture and should not be attempted.)

The nurse is preparing to assess the fetus of a laboring client. Which should the nurse perform first? 1. Place the client into a left lateral position. 2. Perform the Leopold maneuver to determine fetal position. 3. Dry the maternal abdomen before using the Doppler. 4. Count the fetal heart rate for 30 seconds and multiply by 2.

2 (The fetal heart tone assessment should be performed while the client is either supine with a lateral tilt or while in left lateral position. Leopold maneuvers are performed first to determine where to listen for fetal heart tones. This is the first step so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided. Prior to using the Doppler device, a water-based gel is applied to the skin. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold maneuvers to determine fetal position so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided.)

The nurse is admitting a client to the labor and delivery unit. Which aspect of the history requires notifying the healthcare provider? 1. Blood pressure 120/88 2. Dark red vaginal bleeding 3. History of domestic abuse 4. Father is a carrier of sickle-cell trait

2 (Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and fetus.)

The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important? 1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour.

2 (bradycardia is present. Left lateral position increases uterine blood flow.)

The nurse has presented a teaching session on pain relief options to a prenatal class. Which client statement indicates that additional teaching is needed? 1. "An epidural can be continuous or one dose." 2. "General anesthesia is usually recommended for a cesarean section." 3. "Narcotics can be given through a client's epidural infusion catheter." 4. "A pudendal block usually works well to control pain during episiotomy repair."

2 (it would be spinal, not general)

The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? 1. "If I have bleeding in the third trimester of my next pregnancy, I might rupture membranes again." 2. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 3. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 4. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured."

2 (second and third trimester bleeding increases risk for PPROM. UTI increases risk for PPROM, multifetal gestation increases risk for PPROM.)

What should be the nurse's priority when caring for an adolescent in labor? 1. Support persons 2. Developmental level 3. Cultural background 4. Plans for keeping the infant

2 (support is important in anyones care, not just adolescent. Knowing the adolescent's level of development is important because cognitive development is incomplete, which will affect the birthing experience.)

The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? Select all that apply. 1. Drop in blood pressure 2. Increased bloody show 3. Bulging of the perineum 4. Subjective feeling of faintness 5. Uncontrollable urge to bear down

2, 3, and 5

What is the purpose for the client in labor to utilize different breathing techniques? Select all that apply. 1. Reduces pain 2. A source of relaxation 3. A source of distraction 4. Speeds up the delivery process 5. An increased ability to cope with contractions

2, 3, and 5

A client in labor did not attend prenatal classes and is experiencing severe pain. In which breathing technique should the nurse instruct the client to help with relaxation and control? Select all that apply. 1. Kussmaul breathing 2. Abdominal breathing 3. Slow-paced breathing 4. Pant-pant-blow breathing 5. Modified-paced breathing

2 and 4

A client in the midst of labor and delivery of twins is being considered for a podalic version. What should the nurse assess in order for this version to be considered? Select all that apply. 1. Previous cesarean birth 2. Second fetus does not descend 3. Premature rupture of membranes 4. Presence of third-trimester bleeding 5. Second fetus heart rate nonreassuring

2 and 5 (A previous cesarean birth is a contraindication for a version. A podalic version is used only with the second fetus during a vaginal twin birth and only if the twin does not descend readily. Premature rupture of membranes is a contraindication for a version. Presence of third-trimester bleeding is a contraindication for a version. A podalic version is used only with the second fetus during a vaginal twin birth and only if the heart rate is nonreassuring.)

A client entering the third trimester of labor is concerned about having enough muscle strength and stamina to give birth. Which exercises should the nurse review with the client to facilitate the birthing process? Select all that apply. 1. Yoga 2. Pelvic tilt 3. Pelvic rock 4. Kegel exercises 5. McRoberts exercises

2, 3, 4, and 5

The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply. 1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby.

2, 3, and 4

While palpating contractions, the nurse determines that a client is in the latent phase of labor. What findings did the nurse use to make this determination? Select all that apply. 1. Contractions rated as being moderate to strong 2. Contractions rated as being mild to moderate 3. Contractions occur every 6 minutes lasting for 40 seconds 4. Contractions occur every 2 minutes lasting for 50 seconds 5. Contraction occurs every 10 minutes lasting for 30 seconds

2, 3, and 5

The nurse is caring for the newborn of a client who received magnesium sulfate for preterm labor. Which fetal effects should the nurse attribute to the client's medication treatment? Select all that apply. 1. Flushing 2. Lethargy 3. Hypotonia 4. Poor sucking reflex 5. Respiratory depression

2, 3, and 5 (1 is a maternal adverse effect. 4 is not an adverse effect.)

Ketones are present in a urine specimen of a client in the beginning phases of labor. What should the nurse consider as the reason for this laboratory finding? Select all that apply. 1. Edema 2. Vomiting 3. Dehydration 4. Preeclampsia 5. Insulin resistance

2, 3, and 5 (Elevation of the hematocrit may reveal hemoconcentration of blood, which occurs with edema. Ketones in the urine can be associated with vomiting. Ketones in the urine can be associated with dehydration. Proteinuria of 1+ or more may be a sign of impending preeclampsia. Ketones in the urine can be associated with insulin resistance.)

A pregnant client receiving oxytocin for labor induction begins demonstrating adverse effects of the medication. In which order should the nurse provide care to this client? 1. Notify the healthcare provider. 2. Discontinue the oxytocin infusion. 3. Position the client onto the left side. 4. Infuse prescribed intravenous fluids. 5. Administer oxygen 8 to 10 L per tight face mask.

2, 4, 3, 5, and 1

The nurse is assisting with a precipitous birth. In which order should the nurse perform the following actions after the birth of the fetal head? 1. Instruct the client to push. 2. Suction the baby's mouth, throat, and nose. 3. Exert upward traction to the fetal head to facilitate birth of the posterior shoulder. 4. Exert downward traction on the fetal head to facilitate movement of the anterior shoulder.

2, 4, 4, 1

A low-risk client is in the second stage of labor. What actions should the nurse take regarding the auscultation of this client's fetal heart rate? Select all that apply. 1. Evaluate after ambulation. 2. Assess heart sounds every 15 minutes. 3. Evaluate before the membrane rupture. 4. Evaluate before providing medications. 5. Count for 30 seconds and multiply times 2.

2, 4, and 5

A client experiencing a difficult labor is going to have vacuum extraction to facilitate delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "The baby's head might have a bruise from the vacuum cup." 2. "The vacuum will be applied for a total of 10 minutes or less." 3. "I can stop pushing and just rest if the vacuum extractor is used." 4. "A small cup will be put onto the baby's head, and a gentle suction will be applied."

3

A client pregnant with twins asks if the pregnancy will be uncomplicated. How should the nurse respond to this client? 1. "The perinatal mortality rate for monoamniotic siblings is 50%." 2. "Twins are less likely to have complications than are singleton births." 3. "Spontaneously conceived twins are less likely to develop complications." 4. "Primiparous women pregnant with twins are less likely to develop complications."

3

A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. How should the nurse respond to this request? 1. "I will get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I will bring you an extra so that you can change it when you are ready."

3

A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor? 1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4. Occiput anterior (OA) fetal position

3

The client is instructing a client recovering from a classic uterine incision for a cesarean birth. Which statement indicates that the client understands implications for future pregnancies that are secondary to this type of incision? 1. "I can only have one more baby." 2. "The next time I have a baby, I can try to deliver vaginally." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "The risk of rupturing my uterus is too high for me to have any more babies."

3

The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first? 1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push 2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 4. 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously

3

The nurse is counseling a newly pregnant gravida 1 at 8 weeks' gestation with twins about the need for increased caloric intake. What should the nurse emphasize as being the minimum recommended intake? 1. 2500 kcal and 120 g protein 2. 3000 kcal and 150 g protein 3. 3500 kcal and 175 g protein 4. 4000 kcal and 190 g protein

3

A pregnant client is diagnosed with central abruptio placentae. What can the nurse infer about the client's condition? 1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding. 2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage. 3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding. 4. Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding.

3 (1 described marginal placenta separation. 2 is complete abruption, and 4 is marginal abruption)

The home health nurse is visiting the home of a client who is 18 weeks pregnant with twins. Which nursing action is most important? 1. Assess the client's blood pressure in the upper right arm. 2. Collect a cervicovaginal fetal fibronectin (fFN) specimen. 3. Teach the client about foods that are good sources of protein. 4. Determine whether the pregnancy is a result of infertility treatment.

3 (A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth. fetal eclampsia and preterm labor can only be diagnosed at week 20 or later.)

The neonatal nurse specialist is describing neonatal care to nursing students. What statement should the specialist include when describing a proper method for preventing heat loss in the neonate? 1. "After delivery, the newborn is immediately placed in skin-to-skin contact with the mother." 2. "Immediately after delivery, the newborn is wrapped in a blanket and placed on the mother's chest." 3. "If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat." 4. "If a radiant-heated unit is used to keep the neonate warm, the neonate is dried, wrapped in a dry blanket, and placed under the radiant heat."

3 (After delivery, the newborn is dried immediately and wet blankets are removed. Warmed blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The newborn may also be placed under a radiant-heated unit.)

The client in labor has moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a −2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Obtain a clean-catch urine specimen. 2. Apply an internal fetal scalp electrode. 3. Keep the client on bed rest at this time. 4. Encourage the husband to remain in the room.

3 (Because the membranes are ruptured and the head is high in the pelvis at a −2 station, the client should be maintained on bed rest to prevent cord prolapse.)

A client who received a mediolateral episiotomy to facilitate vacuum extraction birth asks what kind of episiotomy was performed. How should the nurse explain the location of the episiotomy? 1. "It goes straight back toward your rectum." 2. "It is from your vagina toward the urethra." 3. "It is cut diagonally away from your vagina." 4. "It extends from your vagina into your rectum."

3 (Midline episiotomy is straight back from the vagina toward the rectum. Episiotomies are not cut anteriorly toward the urethra. Mediolateral episiotomy is angled from the vaginal opening toward the buttock. Extension into the rectum is a fourth-degree laceration.)

A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority? 1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV of lactated Ringer solution. 4. Apply antiembolism stockings.

3 (The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary.)

While caring for a client in labor the nurse determines that the baby's head has internally rotated. The client's spouse asks about other positional changes that will occur during the labor and birth. How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation? 1. Expulsion, external rotation, and restitution 2. Restitution, flexion, external rotation, and expulsion 3. Extension, restitution, external rotation, and expulsion 4. Flexion, extension, restitution, external rotation, and expulsion

3 (The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.)

Five minutes after delivery, the neonate's body is pink with blue extremities. The heart rate is 150. The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate? 1. Rescue breathing and stimulation 2. Stimulation and resuscitative efforts 3. Nasopharyngeal suctioning and blow-by oxygen 4. Oxygen via face mask and endotracheal suctioning

3 (The neonate's Apgar score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called "blow-by" oxygen)

A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4. Monitor maternal blood pressure every 15 minutes.

3 (This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture.)

A postpartum client who received spinal anesthesia for the delivery has not voided for 5 hours and is concerned about nerve damage. How should the nurse respond about this concern? 1. "Spinal anesthesia can sometimes cause nerve damage." 2. "You are probably dehydrated. Please increase your water intake." 3. "It may be several hours before you're able to control your urination." 4. "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you."

3 (may take 8 to 12 hours)

A client's fetal heart rate tracing has a consistent late deceleration pattern. What actions should the nurse take at this time? Select all that apply. 1. Prepare for cesarean birth. 2. Increase intravenous fluids. 3. Monitor maternal blood pressure. 4. Position client on the left side. 5. Apply oxygen 7 to 10 L via face mask.

3, 4, and 5

A pregnant client expresses a desire to use the Lamaze method for the upcoming birth of her child. What should the nurse explain as elements of this birthing process? Select all that apply. 1. Guided imagery 2. Sensory memory 3. Dissociative relaxation 4. Controlled muscle relaxation 5. Differentiated breathing patterns

3, 4, and 5 (Guided imagery is not a technique within the Lamaze method of childbirth. Sensory memory is a technique within the Kitzinger method of childbirth. Dissociative relaxation is used to promote birth as a normal process in the Lamaze method of childbirth. Controlled muscle relaxation is used to promote birth as a normal process in the Lamaze method of childbirth. Specified breathing patterns are used to promote birth as a normal process in the Lamaze method of childbirth.)

A client in labor wants to have a medication-free birth. What should the nurse include when discussing alternatives to pain medication with this client? 1. Emphasize that no medication will be given. 2. Review that the use of medications allows for rest and less fatigue. 3. Explain that pain relief will allow a more enjoyable birth experience. 4. Summarize how maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

4

A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client? 1. Assessing blood pressure every 2 hours 2. Evaluating the fetal heart rate with an internal monitor 3. Limiting vaginal examinations to only one per 24-hour period 4. Monitoring for blood loss, pain, and uterine contractibility

4

A client in labor is being prepared for epidural anesthesia. What should the nurse expect to perform in order to prevent the most common complication associated with this anesthesia? 1. Observe fetal heart rate variability. 2. Place the client in the semi-Fowler position. 3. Teach the client appropriate breathing techniques. 4. Rapidly infuse 500 to 1000 mL of intravenous fluids.

4

A client in labor who is receiving a continuous infusion of a local anesthetic through an epidural catheter asks if ear ringing is supposed to occur. What is the most likely cause of the client's complaint? 1. Dehydration 2. Hypotension 3. Allergic reaction 4. Local anesthetic toxicity

4

A client in labor who rates pain as 9 on a scale from 0 to 10 requests pain medication after refusing epidural anesthesia. What action should the nurse take prior to administering butorphanol tartrate (Stadol) as prescribed? 1. Offer epidural anesthesia again. 2. Administer oxygen via face mask at 6 to 10 L per minute. 3. Obtain maternal vital signs and assess the fetal heart rate (FHR). 4. Instruct on the actions and contraindications associated with the medication.

4

Prior to receiving lumbar epidural anesthesia, in which position should the nurse place the client in labor? 1. Lying prone with a pillow under the chest 2. On the right side in the center of the bed with the back curved 3. On the left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed with the back slightly curved and feet on a stool

4

For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. What should the nurse include when explaining the location of the episiotomy to the client? 1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4. "Through your rectal sphincter."

4 (A periurethral laceration is near the urethra. A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle. A fourth-degree laceration is through the rectal mucosa. A third-degree laceration includes the rectal sphincter.)

A client at 39 weeks' gestation being prepared for labor induction feels as though the baby has "flipped." What action should the nurse take? 1. Evaluate fetal maturity. 2. Administer dinoprostone (Cervidil) vaginal gel. 3. Implement continuous electronic fetal monitoring (EFM). 4. Notify the healthcare provider that the client feels as though the baby has changed position.

4 (Because malpresentation, such as breech, is a relative contraindication to induction of labor, the client will require additional evaluation by the healthcare provider before proceeding.)

The charge nurse is reviewing the plans of care for four clients in labor. Which care plan requires additional information before implementing? 1. Administration of a spinal anesthetic to a client who is scheduled for a vaginal delivery 2. Administration of a spinal anesthetic to a client with a history of irritable bowel syndrome (IBS) 3. Administration of epidural anesthesia to a client who is in the first stage of labor and has a shellfish allergy 4. Administration of epidural anesthesia to a client with a history of vomiting secondary to hyperemesis gravidarum

4 (Contraindications to epidural anesthesia include severe hypovolemia of any etiology. The client with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia.)

The clinical instructor reviews postoperative care of cerclage with a group of nursing students. Which student statement indicates the need for further information? 1. "Sometimes cerclage can be performed on an outclient basis." 2. "If cerclage is performed emergently, the client will usually be hospitalized for at least 5 days." 3. "After 37 weeks' gestation, the client's cerclage may be cut in order to allow for vaginal delivery." 4. "If the client's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed."

4 (Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure.)

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. "Multipara, transverse lie." 2. "Primipara failed ECV last week." 3. "Primipara, frank breech ballotable." 4. "Multipara, 32 weeks, complete breech."

4 (ECV is not attempted until 36 weeks. This client is too early in her pregnancy for ECV.)

A client's amniotic fluid is meconium stained. What should the nurse do immediately? 1. Change the client's position in bed. 3. Administer oxygen at 2 L per minute. 2. Notify the healthcare provider that birth is imminent. 4. Begin continuous fetal heart rate monitoring.

4 (Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring.)

The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Determine the color of the leaking amniotic fluid. 2. Apply oxygen to the client at 2 L per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Assist the client to change from the Fowler position to the left lateral position.

4 (Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable. The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the client might get the fetus off the cord and eliminate the variable decelerations.)

The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention? 1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."

4 (Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This client will be grieving but is not experiencing physical complications. Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This client might be experiencing a complication, but it is a lower priority than the client with the possibility of a prolapsed cord. Although this client is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency. Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.)

After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing? 1. Infection 2. Placenta accreta 3. Hypertensive crisis 4. Amniotic fluid embolus

4 (Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.)

A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time? 1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4. Assist the client to squat during the second stage.

4 (Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.)

A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. What action should the nurse make a priority at this time? 1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD).

4 (The client is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions.)

For which reason should the nurse suspect hydramnios in a pregnant client? 1. The client is pregnant with twins. 2. The quadruple screen comes back positive. 3. There is less amniotic fluid than normal for gestation. 4. The fundal height increases disproportionately to the gestation.

4 (The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation.)

What should the nurse anticipate the labor pattern for a fetal occiput posterior position to be? 1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4. Prolonged with regard to the overall length of labor

4 (The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor.)

The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. What risk factors should the nurse include about this health problem? Select all that apply. 1. Multiparity 2. Preterm labor 3. Diabetes mellitus 4. Abruptio placentae 5. Prolonged retention of a fetus after demise

4 and 5

The primiparous client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? a. "You should not work so much at this point in pregnancy." b. "Your body may be telling you it is going into labor soon." c. "If the bladder pressure continues, come in to the clinic tomorrow." d. "What you are describing is not commonly experienced in the last weeks."

b (lightening is being described)

The nurse is teaching a prenatal class. What characteristics about false labor should the nurse include? Select all that apply. a. Increased thin vaginal secretions b. Pain in the abdomen that does not radiate c. Progressive cervical effacement and dilatation d. Contractions that do not intensify while walking e. An increase in the intensity and frequency of contractions

b and d (True labor results in an increase in vaginal secretions. True labor results in pain beginning low in the abdomen and radiating upward or into the back. True labor results in progressive dilation. True labor contractions intensify while walking. True labor results in increased intensity and frequency of contractions.)

The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply. a. Multipara at 3 cm, fetus in longitudinal lie b. Primipara at 7 cm, fetus in military attitude c. Multipara at 6 cm, fetus at −2 station, mild contractions d. Primipara at 5 cm, fetal presenting part is right shoulder e. Primipara at 4 cm, fetus with macrocephaly due to hydrocephalus

b, c, d, and e (Lie refers to the relationship between the cephalocaudal axis of the mother and the cephalocaudal axis of the fetal body; longitudinal lie is normal. Attitude refers to the relationship of the fetal parts to one another. Military attitude is an unflexed neck; normal fetal attitude is flexion of the neck. Military attitude creates a larger diameter of the head fitting through the pelvis. This client is experiencing a problem between the maternal pelvis and the presenting part. Station refers to how low in the pelvis the baby's presenting part is; −2 station is high in the pelvis. Contractions should be strong to cause fetal descent and cervical dilation. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. The presenting part is the fetal part coming through the cervix. The occiput or back of the baby's head is the most common and most effective presenting part. A shoulder presentation cannot deliver vaginally and will require a cesarean birth. This client is experiencing a problem between the maternal pelvis and the presenting part. Hydrocephalus can lead to macrocephaly, or an abnormally large head. Macrocephalic babies might not fit through the bony pelvis and could require birth by cesarean section. This client is experiencing a problem between the maternal pelvis and the presenting part.)

A client whose cervix is dilated 8 cm is restless and frequently changing position in an attempt to get comfortable. Which nursing action is most important? a. Leave the client alone so she can rest. b. Ask the family to take a coffee and snack break. c. Reassure the client that she will not be left alone. d. Encourage the client to have an epidural for pain.

c

The primiparous client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? a. "Come in for an appointment today and we will check everything out." b. "Unless you have pain with urination, we do not need to worry about it." c. "This might indicate that the baby is no longer in a head down position." d. "These symptoms usually mean the baby's head has descended further."

d

The primiparous client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. How should the nurse respond to this client? a. "What did you expect? You have only had contractions for a few hours. Labor takes time." b. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." c. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix." d. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

d (Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much longer than do subsequent labors and births.)