PrepU Test 4

A primary care provider has prescribed nalbuphine hydrochloride 10 mg intravenously for a client in active labor. The pharmacy supplies a vial labeled as 50 mg in a 5-mL vial. How many milliliters should the nurse administer? Record your answer using a whole number.

1

The nurse is caring for a client at 36 weeks' gestation with a temperature of 101.2° F (38.4° C). Examination indicates that the client is leaking amniotic fluid. The nurse understantds that what is the probable cause of the client's fever?

Intrauterine infection.

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which of the following positions would the nurse assist the client?

Left lateral

During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. What is the nurse's priority intervention?

Massage the client's fundus.

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

Reposition the client to her left side.

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?

Reposition the client, apply oxygen, and increase IV fluids.

A woman's breasts undergo anatomic and physiologic changes during pregnancy and lactation. Which of the following is true?

The alveolar cells being to secrete colostrum.

A client with gestational hypertension receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client?

To prevent seizures

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

beginning of one contraction to the beginning of the next contraction

How does the nurse identify the type of presentation shown in the figure?

complete breech

A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?

danger signs during pregnancy

The end of the third stage of labor is marked by what event?

delivery of the placenta

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

duration, frequency, and intensity

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?

early decelerations

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

fetal heart rate variability within 5 to 10 beats/minute

A 19-year-old primigravida at 38 weeks' gestation, in active labor for the past 8 hours, is admitted to the hospital accompanied by her mother. On admission, the client's cervix is 5 cm dilated, her blood pressure is 120/84 mm Hg, and she is breathing rapidly, feeling dizzy and light-headed. The nurse determines that the client is most likely experiencing effects of which factor?

hyperventilation

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?

hypotension.

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?

left lateral

What assessment data of a laboring woman would require further intervention by the nurse?

maternal heart rate 125 beats/minute

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

maternal hypotension

The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding?

passage of meconium by the fetus

A client in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history, what should the nurse suspect?

placenta previa

The health care provider (HCP) has prescribed prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which finding indicates that the client has had a therapeutic response to the medication?

softening of the cervix and beginning effacement

When the nurse is working in the mother-baby unit, which client would the nurse anticipate giving Rho(D) immune globulin (human) to?

the Rh-negative mother with an Rh-positive baby

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure?

umbilical cord

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

umbilical cord prolapse

External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first?

Change the client's position.

What data indicates to the nurse that placental detachment is occurring?

an abrupt lengthening of the cord

A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?

Continuous fetal heart rate monitoring will be implemented.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

Check the fetal heart rate.

The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention?

Prepare for an emergency cesarean birth.

A nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?

They're usually felt in the abdomen.

A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin infusing. What is the nurse's best response?

"Let me help you sit up on the side of the bed."

A nurse is caring for a client who is anxious to know her baby's due date. The nurse instructs the client on how to determine the baby's due date according to Naegele's rule. The client is correct to state which comment when discussing the use of the rule? Select all that apply.

"Naegele's rule provides a good approximation of the due date." "I will add 7 days to the first day of my last menstrual period and count back 3 months." "Naegele's rule may be used in conjunction with other assessment findings."

A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated vaginal birth. What should the nurse should tell the client?

"The maximum blood loss considered within normal limits is 500 ml."

A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first?

Initiate fetal and contraction monitoring.

A woman who has preeclampsia is receiving magnesium sulfate 20 grams per 500 mL of lactated Ringers via infusion pump. The prescribed rate of infusion is 2 grams/hour. How many mL/hour should the nurse set the infusion pump for? Record your answer using a whole number.

50

A client is at risk for seizures due to pregnancy-induced hypertension. The healthcare provider orders 4 g magnesium sulfate in 250 ml D5W to be infused at 1 g/hour following a loading dose. What is the flow rate in milliliters per hour? Record your answer using a whole number.

63

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?

Assess the fetal heart rate.

A client with diabetes mellitus gives birth to a 9-lb, 10-oz (4375 g) neonate at 38 weeks. What is the nurse's priority action after the stabilization of the neonate?

Assess the neonate's blood glucose level.

A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?

Edema

A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next?

Inform the physician and prepare for discharge; this client has a normal strip.

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention?

Massage the fundus.

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first?

Note the color, amount, and odor of the amniotic fluid.

A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), what should the nurse do?

Turn the client to her side.

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point?

at about the level of the client's umbilicus

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse?

blood pressure of 146/90 mm Hg

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation?

breech position

During the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?

headache, blurred vision, and facial and extremity swelling

A 16-year-old unmarried client visiting the prenatal clinic at 32 weeks' gestation and currently weighing 140 lb (63.5 kg) is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inch (158 cm) tall and weighed 120 lb (54.4 kg) before the pregnancy. Which factor would be most important to assess?

proteinuria

After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed?

"I should try to push with each contraction."

A primigravid client at 24 weeks' gestation has received permission from the primary care provider to make a 6-hour automobile trip to visit her parents. After the nurse teaches the client about precautions to take during the trip, which client statement indicates the need for further instruction?

"I'll sleep for 1 hour at the halfway point of the trip."

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 is at an ideal weight when she conceives. During a prenatal visit 2 months later, the client asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response?

"You should gain 25 to 35 lb (11.3 to 15.9 kg)."

A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 ml normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using a whole number.

50

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first?

Assess the fetal heart rate (FHR) for 1 full minute.

A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

Change the client's position.

The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first?

Change the client's position.

The nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?

Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg

A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next?

Reposition the client and evaluate the tracing.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?

The cord lengthens outside the vagina.

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

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

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

an increased sense of rectal pressure

In which maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior (LOA) position?

below the umbilicus on the left side

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important?

fetal heart rate

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

fetal presentation

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?

promoting adequate hydration