PassPoint - Intrapartum Period
The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider?
"My membrane ruptured 2 days ago."
Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first?
"What is your expected due date?"
A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply.
-Use the hospital code for HIV when documenting care. -Ask all family members, except the client's significant other, to wait outside when she's educating the client.
The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN?
A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?
Collaborate with the physician to make a referral to social services.
A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take?
Contact the health care provider, supporting the client until an analgesic is prescribed.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?
Contractions will be stronger and more uncomfortable and will peak more abruptly.
Which action should the nurse take to promote the descent of the fetus's presenting part?
Encourage the client to void every 2 hours.
The third stage of labor ends after the birth of the placenta. Which action should the nurse take immediately following the birth of the placenta?
Examine the placenta for completeness.
A client in the first stage of labor is agitated, upset, and crying. The client expressed concern about being in labor for 32 hours the last time she gave birth. Based on this information, the nurse should expect which nursing diagnosis in the client's plan of care?
Fear related to a potentially difficult childbirth
A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?
Massage the fundus.
A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action?
Notify the physician that the partner has been waiting to discuss the mother's condition.
A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take?
Reposition the client to left lateral position.
A nurse is caring for a pregnant client who is scheduled to undergo an amniotomy to induce labor. After the procedure, which client goal should take the highest priority?
The fetus will maintain adequate tissue perfusion.
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress?
blood pressure of 146/94 mm Hg
A client gives birth to a 9-lb, 10-oz (4.4-kg) neonate vaginally, with a midline episiotomy. Shortly after birth, the client reports to a nurse that she is not feeling well. In monitoring the client for possible uterine hemorrhage, the nurse should report which findings?
cool, clammy, pale skin and anxiety
A multiparous client admitted to the labor unit has not received prenatal care for this pregnancy. When collecting information from this client, which data would be most important to obtain?
date of last menstrual period (LMP)
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them?
the client's partner
