Unit 4 - Intrapartum

The fetal heart rate baseline is 140 beats/min. 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? A) Assist the client to change position. B) Apply oxygen to the client at 2 liters per nasal cannula. C) Notify the operating room of the need for a cesarean birth. D) Determine the color of the leaking amniotic fluid

A) Assist the client to change position The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava

The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? A) Document the fetal heart rate. B) Apply oxygen via mask at 10 liters. C) Prepare for imminent delivery. D) Assist the client into Fowler's position.

A) Document the fetal heart rate The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary

Before performing Leopold maneuvers, what would the nurse do? Select all that apply. A) Have the client empty her bladder. B) Place the client in Trendelenburg position. C) Have the client lie on her back with her feet on the bed and knees bent. D) Turn the client to her left side. E) This is not the optimal position for the client when performing Leopold maneuvers.

A) Have the client empty her bladder. C) Have the client lie on her back with her feet on the bed and knees bent. Explanation: A) The woman should have recently emptied her bladder before performing Leopold maneuvers. B) Placing the client in Trendelenburg position is not consistent with accurately performing Leopold maneuvers. C) The woman should lie on her back with her abdomen uncovered. To aid in relaxation of the abdominal wall, the shoulders should be raised slightly on a pillow and the knees drawn up a little. D) Placing the client on her left side is not consistent with accurately performing Leopold maneuvers. Page Ref: 473

The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus? A) Infection B) Umbilical cord compression C) Vagus nerve stimulation D) Hypoxemia

A) Infection Explanation: A) Infection is one of the most common causes of fetal tachycardia. B) Umbilical cord compression may result in bradycardia, not tachycardia. C) Vagus nerve stimulation may result in bradycardia, not tachycardia. D) Hypoxemia may result in bradycardia, not tachycardia. Page Ref: 482

The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? A) Inform the maternal client that the rate is normal. B) Reassess the FHR in 5 minutes because the rate is low. C) Report the FHR to the doctor immediately. D) Turn the maternal client on her side and administer oxygen

A) Inform the maternal client that the rate is normal. Normal = 110-160bpm

The nurse is assessing the baseline fetal heart rate for a client in labor. What action should the nurse take first? A) Measure the fetal heart rate for 10 minutes B) Round the heart rate to increments of 5 beats/minute C) Exclude periods of marked variation D) Calculate the mean (average) heart rate

A) Measure the fetal heart rate for 10 minutes Explanation: A) The first action the nurse should take is measuring the fetal heart rate for 10 minutes. B) The nurse should round the fetal heart rate to increments of 5 beats/minute after taking a 10-minute measurement of the fetal heart rate. C) The nurse should exclude periods of marked variation after taking a 10-minute measurement of the fetal heart rate. D) The nurse should calculate the mean (average) heart rate after taking a 10-minute measurement of the fetal heart rate. Page Ref: 482

The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? A) Perform Leopold maneuvers to determine fetal position. B) Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (UC). C) Dry the maternal abdomen before using the Doppler. D) The diaphragm should be cooled before using the Doppler.

A) Perform Leopold maneuvers to determine fetal position.

The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? A) Woman at 7 cm, fetal heart tones auscultated every 90 minutes B) Woman at 10 cm and pushing, external fetal monitor applied C) Woman with meconium-stained fluid, internal fetal scalp electrode in use D) Woman in preterm labor, external monitor in place

A) Woman at 7 cm, fetal heart tones auscultated every 90 minutes Explanation: A) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough. B) External monitoring can be done instead of auscultation of the fetal heart tones during labor. C) Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present D) External monitoring during preterm labor will assess both contractions and fetal status. Page Ref: 469

A nurse is caring for a client having contractions every 8 minute that are 30 to 40 seconds in duration. The clients cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 stations with a FHR around 140/min. Which of the following stages and phases of labor is this client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor

A. First stage, latent phase In stage 1, latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds -in stage 1, active phase, the cervix dilates from 4 to 7 cm, and contraction duration ranges from 40 to 70 seconds -in stage 1, transition phase, the cervix dilates from 8 to 10 cm, and contraction duration ranges from 45 to 90 seconds -The second stage of labor consists of the expulsion of the fetus

A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and a vaginal delivery is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic blocks is to be administered? A. pudendal B. epidural C. spinal D. para-cervical

ANS: A A pudendal block is a trans-vaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy & repair, and the expulsion of the fetus

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. assist the client into the left-lateral position B. apply a fetal scalp electrode C. insert an IV catheter D. Perform a vaginal exam

ANS: A The greatest risk to the fetus during late decelerations is utero-placental insufficiency. The initial nursing action should be to place the client into the left lateral position to increase utero-placental perfusion

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? A. it is needed to promote increased urine output B. it is needed to counteract the respiratory depression C. It is needed to counteract hypotension D. it is needed to prevent oligohydramnios

ANS: C Maternal hypotension can occur following an epidural block and can be offset by administering an IV fluid bolus

A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? (SATA) A. lengthening of the umbilical cord B. swift gush of clear amniotic fluid C. softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation

ANS: A, D, E

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. apply palms of both hands to sides of uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb & fingers D. stand facing client's feet with fingertips outlining cephalic prominence

ANS: B Palpating the fundus of the uterus identifies the fetal part that is present, indicating the fetal lie (longitudinal or transverse)

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A. assist the client to the bathroom B. prepare for impending delivery C. prepare to remove fecal impaction D. encourage the client to take deep, cleansing breaths

ANS: B The urge to have a bowel movement indicates fetal descent and complete dilation

A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following non-pharmacological nursing interventions should the nurse recommend to the client? A. abdominal effleurage B. sacral counter-pressure C. showering if not contraindicated D. back rub and massage

ANS: B sacral counter-pressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus

A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hrs. Which of the following statements should the nurse make? A. a full bladder increases the risk of fetal trauma B. a full bladder increases the risk for bladder infections C. a distended bladder will be traumatized by frequent pelvic exams D. a distended bladder reduces pelvic space needed for birth

ANS: D A distended bladder reduces pelvic space, impedes fetal descent, and places the bladder at risk for trauma during the labor process

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? A. peak of uterine contraction B. moderate variability C. FHR acceleration D. relaxation between uterine contractions

ANS: D A fetus is most oxygenated during the relaxation period between contractions. During the contractions, the arteries to the utero-placental intervillous spaces are compressed, resulting in a decrease in fetal circulation

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. administer O2 via nasal cannula @ 2L/min B. apply a warm blanket C. assist the client to a side-lying position D. place an O2 mask over the client's mouth and nose

ANS: D The client is experiencing hyperventilation caused by low blood levels of PCO2. Placing an O2 mask over the client's nose and mouth or having the client breathe into a paper bag will reduce the intake of O2, allowing the PCO2 to rise and alleviate the numbness & tingling

A client calls a provider's office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions

ANS: D True contractions Do not go away with hydration or walking. They are regular in frequency, duration, and intensity and become stronger with walking -Braxton Hicks decrease with hydration and walking -Rupture of membranes would be indicated by the presence of a gush of fluid that is unrelated to the client's activity -Fetal descent is the downward movement of the fetus in the birth canal and cannot be evaluated based on the clients report REF: ATI

A nurse is planning care for a newly admitted client who reports "I am in labor and have had vaginal bleeding for 2 weeks". Which of the following should the nurse include in the plan of care? A. inspect the introitus for a prolapsed cord B. Perform a test to identify the ferning pattern C. Monitor station of the presenting part D. Defer vaginal examinations

ANS: D Vaginal examinations should not be performed until placenta previa or abruptio has been ruled out as the cause of vaginal bleeding

The nurse is caring for a client in labor who has a history of physical dependence on narcotics. Which consideration should the nurse take with regard to the administration of naloxone (Narcan)? A) Inducing withdrawal symptoms B) Prolonging respiratory depression C) Exacerbating pruritis D) Increasing the risk for fetal depression

Answer: A Explanation: A) Administering naloxone (Narcan) to a client who is physically dependent on narcotics may induce withdrawal symptoms, which will adversely affect her and her baby. B) Naloxone (Narcan) is used to correct respiratory depression, and does not prolong it. C) Naloxone is an opiate antagonist, and is not expected to exacerbate the side effects of opioids such as pruritis. D) Fetal depression is not expected to occur with the use of naloxone (Narcan). Page Ref: 534

A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? A) Spinal B) Pudendal C) General D) Epidural

Answer: A Explanation: A) Following the birth, the woman may be kept flat. Although the effectiveness of the supine position to avoid headache following a spinal is controversial, the physician's orders may include lying flat for 6-12 hours. B) It is not necessary to keep the postpartum client in bed for 6-12 hours after receiving a pudendal. C) The decision to keep the postpartum client in bed after receiving a general anesthesia depends on the client. D) It is not usually necessary to keep the postpartum client in bed for 6-12 hours after receiving an epidural. Page Ref: 547

An analgesic medication has been administered intramuscularly to a client in labor. How would the nurse evaluate if the medication was effective? A) The client dozes between contractions. B) The client is moaning during contractions. C) The contractions decrease in intensity. D) The contractions decrease in frequency.

Answer: A Explanation: A) If the client dozes between contractions, the analgesic is effective. Analgesics decrease discomfort and increase relaxation. B) Analgesics decrease the discomfort of contractions. C) Contractions will not decrease in intensity. D) Contractions will not decrease in frequency. Page Ref: 529

A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? A) A soaked perineal pad since the last 15-minute check B) An edematous perineum C) The client experiencing tremors D) A fundus located at the umbilicus

Answer: A Explanation: A) If the perineal pad becomes soaked in a 15-minute period, or if blood pools under the buttocks, continuous observation is necessary. As long as the woman remains in bed during the first hour, bleeding should not exceed saturation of one pad. B) An edematous perineum is a normal postpartal finding. C) Tremors are a normal postpartal finding. D) A fundus located at the umbilicus is a normal postpartal finding. Page Ref: 523

What is the major adverse side effect of epidural anesthesia? A) Maternal hypotension B) Decrease in variability of the F H R C) Vertigo D) Decreased or absent respiratory movements

Answer: A Explanation: A) The major adverse effect of epidural anesthesia is maternal hypotension caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers blood pressure. B) A decrease in variability of the F H R is a fetal side effect of benzodiazepines. C) Vertigo is a side effect of the drug Nubain. D) Meperidine has multiple fetal side effects, including decreased or absent respiratory movements. Page Ref: 539

The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? A) Hyperventilation B) Seizure auras C) Imminent birth D) Anxiety

Answer: A Explanation: A) These symptoms all are consistent with hyperventilation. B) Seizure auras do not have these symptoms. C) Imminent birth does not have these symptoms. D) Anxiety does not have these symptoms. Page Ref: 508

By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? A) Recognizing the client as an active participant in her own care. B) Attempting to correct any misinformation the client might have received. C) Acting as an advocate for the client. D) Establishing rapport with the client.

Answer: A Explanation: A) Understanding the couple's expectations and plans helps the nurse provide optimal nursing care and facilitate the best possible birth experience. B) Any misinformation the family has can be corrected, but that is not the primary focus. C) The nurse might use the information about plans and expectations to act as an advocate for the client as the labor progresses, but this is not the primary rationale for inquiring about them. D) Rapport and a therapeutic relationship are important for all nurse-client interactions, but are not best addressed by asking about plans and expectations for the birth. Page Ref: 499

The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? A) Check fetal heart tones. B) Encourage the mother to go for a walk. C) Change bed linens. D) Call the physician.

Answer: A Explanation: A) When the membranes rupture, the nurse notes the color and odor of the amniotic fluid and the time of rupture and immediately auscultates the F H R. B) If there has been a rupture of membranes, the laboring client should not be allowed to walk. C) The bed linens can be changed after assessing the heart rate. D) The physician does not need to be called after rupture of the membranes unless there is a change in the status of the fetus or client. Page Ref: 503

How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? A) Breech, transverse B) Breech, longitudinal C) Breech, frank D) Vertex, transverse

Answer: A Explanation: A) A shoulder presentation is one type of breech presentation and is also called a transverse lie. B) A shoulder presentation is not a longitudinal lie. C) In a frank breech, the buttocks are the presenting part. D) A shoulder presentation is not vertex. Page Ref: 435

A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? A) Cervical dilation 6 cm B) Mild contraction intensity C) Contraction frequency every 5 minutes D) Contraction duration 30-40 seconds

Answer: A Explanation: A) Cervical dilation of 6 cm indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 cm and contractions and pain intensify. B) Mild contractions are consistent with most of the scenario. C) This contraction frequency is consistent with most of the scenario. D) This contraction duration is consistent with most of the scenario. Page Ref: 444

To identify the duration of a contraction, the nurse would do which of the following? A) Start timing from the beginning of one contraction to the completion of the same contraction. B) Time between the beginning of one contraction and the beginning of the next contraction. C) Palpate for the strength of the contraction at its peak. D) Time from the beginning of the contraction to the peak of the same contraction.

Answer: A Explanation: A) The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction. B) Duration is not measured this way. C) Duration is not measured this way. D) Duration is not measured this way. Page Ref: 437

The 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. What is the nurse's best response to the client? A) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." B) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."

Answer: A Explanation: A) With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls. B) As the fetal head descends to the pelvic floor, the pressure of the presenting part causes the perineal structure, which was once 5 cm in thickness, to change to a structure less than 1 cm thick. The perineal body's thinning primarily occurs during later stages of labor; it is not expected now. C) This reply is not therapeutic. The nurse must always be therapeutic in all communication. D) The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change. Page Ref: 440

The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Select all that apply. A) Maternal exhaustion B) Cervical edema C) Tearing and bruising of the cervix D) Enhanced perineal thinning E) Having to perform an episiotomy

Answer: A, B, C Explanation: A) If the cervix is not completely dilated, maternal exhaustion can occur. B) If the cervix is not completely dilated, cervical edema can occur. C) If the cervix is not completely dilated, tearing and bruising of the cervix can occur. D) Cervical dilation has nothing to do with perineal thinning. E) Not bearing down until the cervix is completely dilated has nothing to do with needing an episiotomy. Page Ref: 437

Premonitory signs of labor include which of the following? Select all that apply. A) Braxton Hicks contractions B) Cervical softening and effacement C) Weight gain D) Rupture of membranes E) Sudden loss of energy

Answer: A, B, D Explanation: A) A premonitory sign of labor includes Braxton Hicks contractions. B) A premonitory sign of labor includes cervical softening and effacement. C) A premonitory sign of labor includes weight loss, not weight gain. D) A premonitory sign of labor includes rupture of membranes. E) A premonitory sign of labor includes a sudden burst of energy, not a loss of energy. Page Ref: 440

A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Select all that apply. A) Android B) Anthropoid C) Gynecoid D) Platypelloid E) Lambdoidal suture

Answer: A, D Explanation: A) In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. B) The anthropoid pelvis type is considered favorable for vaginal childbirth. C) The gynecoid pelvis type is considered favorable for vaginal childbirth. D) In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. E) This is not a pelvis type. Page Ref: 431

A client who is having false labor most likely would have which of the following? Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) Contractions that lessen with rest and warm tub baths

Answer: A, D, E Explanation: A) True labor contractions intensify while walking. B) The contractions of true labor produce progressive dilation and effacement of the cervix. They occur regularly and increase in frequency, duration, and intensity. C) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. D) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. E) In true labor, contractions do not lessen with rest and warm tub baths.

The client at 39 weeks' gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention? A) The baby's hands and feet are blue at 1 minute after birth. B) The fetal heart rate is 70 prior to making the skin incision. C) Clear fluid is obtained from the baby's oropharynx. D) The neonate cries prior to delivery of the body.

Answer: B Explanation: A) Acrocyanosis is an expected finding at 1 minute of age. B) Fetal bradycardia occurs when the fetal heart rate falls below 110 beats/minute during a 10-minute period of continuous monitoring. When fetal bradycardia is accompanied by decreased variability, it is considered ominous and could be a sign of fetal compromise. C) Clear fluid from the baby's oropharynx is an expected finding. D) A primary danger of general anesthesia is fetal depression. Crying after delivery of just the head indicates that no neonatal depression has occurred. Page Ref: 551

Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do? A) Be used in place of preoperative sedation B) Result in neonatal respiratory depression C) Prevent the need for anesthesia with an episiotomy D) Enhance uterine contractions

Answer: B Explanation: A) Analgesics do not take the place of preoperative sedation. B) Analgesia given too late is of no value to the woman and may cause neonatal respiratory depression. C) Local anesthetic is needed for an episiotomy. D) Analgesics do not enhance uterine contractions. Page Ref: 531

The laboring client brought a written birth plan indicating that she wanted to avoid pain medications and an epidural. She is now at 6 c m and states, "I can't stand this anymore! I need something for pain! How will an epidural affect my baby?" What is the nurse's best response? A) "The narcotic in the epidural will make both you and the baby sleepy." B) "It is unlikely that an epidural will decrease your baby's heart rate." C) "Epidurals tend to cause low blood pressure in babies after birth." D) "I can't get you an epidural, because of your birth plan."

Answer: B Explanation: A) It is rare for sedation to occur from absorption of the medications of a continuous epidural. B) Maternal hypotension results in uteroplacental insufficiency in the fetus, which is manifested as late decelerations on the fetal monitoring strip. The risk of hypotension can be minimized by hydrating the vascular system with 500 to 1000 m L of I V solution before the procedure and changing the woman's position and/or increasing the I V rate afterward. C) Mothers can experience hypotension after the epidural is administered, but babies do not develop hypotension after birth as a result of a labor epidural. D) A birth plan is what the client hopes for prior to the onset of labor, but it can be modified at any time. Page Ref: 542

The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 c m 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? A) Encourage the husband to remain in the room. B) Keep the client on bed rest at this time. C) Apply an internal fetal scalp electrode. D) Obtain a clean-catch urine specimen.

Answer: B Explanation: A) It is unknown from the given information whether it is culturally appropriate for the client's husband to remain in the room for the labor and birth. B) 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. C) An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This client has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present. D) A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid contamination might falsely increase the reading of protein present. Page Ref: 506

Upon delivery of the newborn, what nursing intervention most promotes parental attachment? A) Placing the newborn under the radiant warmer. B) Placing the newborn on the mother's abdomen. C) Allowing the mother a chance to rest immediately after delivery. D) Taking the newborn to the nursery for the initial assessment.

Answer: B Explanation: A) Removing the baby from the mother does not promote attachment. B) As the baby is placed on the mother's abdomen or chest, she frequently reaches out to touch and stroke her baby. When the newborn is placed in this position, the father or partner also has a very clear, close view and can reach out to touch the baby. C) Removing the baby from the mother does not promote attachment. D) Removing the baby from the mother does not promote attachment. Page Ref: 519

Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position? A) On her right side in the center of the bed with her back curved B) Lying prone with a pillow under her chest C) On her left side with the bottom leg straight and the top leg slightly flexed D) Sitting on the edge of the bed

Answer: D Explanation: D) The woman is positioned on her left or right side, at the edge of the bed with the assistance of the nurse, with her legs slightly flexed, or she is asked to sit on the edge of the bed. Page Ref: 540

The laboring client is at 7 c m, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? A) Fear/Anxiety related to discomfort of labor and unknown labor outcome B) Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent C) Coping: Family, Compromised, related to labor process D) Knowledge, Deficient, related to lack of information about normal labor process and comfort measures

Answer: B Explanation: A) The client is not exhibiting fear or anxiety, but acute pain; therefore, this diagnosis does not fit. B) The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor. C) There is no evidence regarding the family's coping, only the client's coping with the pain. D) The client used breathing and relaxation techniques earlier in labor, demonstrating knowledge of these techniques. Page Ref: 498

A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor? A) Nausea B) Bladder distention C) Uterine atony D) Hypertension

Answer: B Explanation: A) The epidural is discontinued after delivery, decreasing the likelihood of nausea. B) Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention. C) Uterine atony is not a result of epidurals. D) Hypotension, not hypertension, is an early side effect of epidurals. Page Ref: 544

The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? A) The sterile vaginal exam B) Welcoming the couple C) Auscultation of the fetal heart rate D) Checking for ruptured membranes

Answer: B Explanation: A) The sterile vaginal exam should be performed after maternal vital signs have been assessed. B) It is important to establish rapport and to create an environment in which the family feels free to ask questions. The support and encouragement of the nurse in maintaining a caring environment begins with the initial admission. C) The fetal heart rate should be listened to after the client is made comfortable. D) Assessing for intact or ruptured membranes is a part of the admission assessment after the client is made comfortable. Page Ref: 507

The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? A) Client at 5 cm requesting labor epidural analgesia B) Client whose cervix remains at 6 cm for 4 hours C) Client who has developed nausea and vomiting D) Client requesting her partner to stay with her

Answer: B Explanation: A) Contacting the supervisor is required when an abnormal situation is present. Requests for medication are not abnormal. B) Average cervical change in the active phase of the first stage of labor is 1.2 cm/hour; thus, this client's lack of cervical change is unexpected, and should be reported to the supervisor. C) Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation is present. D) Clients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present. Page Ref: 444

A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? A) Active B) Transition C) Latent D) Second

Answer: B Explanation: A) During the active phase, the cervix dilates from about 4 to 7 cm. When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. B) During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety. C) The latent phase is characterized by mild contractions lasting 20 to 40 seconds with a frequency of 3 to 30 minutes. In the latent stage, the woman may be relieved that labor has finally started. D) The second stage is the pushing stage, and the woman might feel relieved that the birth is near and she can push. There is no second phase of labor. Page Ref: 444

A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? A) Engagement B) Lightening C) Molding D) Braxton Hicks contractions

Answer: B Explanation: A) Engagement of the presenting part occurs when the largest diameter of the fetal presenting part reaches or passes through the pelvic inlet. B) Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet. C) The fetal cranial bones overlap under pressure of the powers of labor and the demands of the unyielding pelvis. This overlapping is called molding. D) Braxton Hicks contractions occur before the onset of labor. Page Ref: 440

Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? A) Place the client in McRoberts position. B) Watch for the emergence of the placenta. C) Prepare for the delivery of an undiagnosed twin. D) Place the client in a supine position.

Answer: B Explanation: A) Exercises aimed at adducting the legs into an extended McRoberts position, which is performed by flexing the mother's thighs toward her shoulders while she is lying on her back, help enable the woman to stretch her hamstring muscles, a task usually required during the second stage of labor. B) Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina. C) The first placenta usually does not deliver before the birth of the second twin. D) Blood pressure may drop precipitously when the pregnant woman lies in a supine position and experiences aortocaval compression. Page Ref: 445

Which client requires immediate intervention by the labor and delivery nurse? A) Client at 8 cm, systolic blood pressure has increased 35 mmHg B) Client who delivered 1 hour ago with WBC of 50,000/mm3 C) Client at 5 cm with a respiratory rate of 22 between contractions D) Client in active labor with polyuria

Answer: B Explanation: A) In the first stage, systolic pressure may increase by 35 mmHg, and there may be further increases in the second stage during pushing efforts. B) The white blood cell (WBC) count increases to between 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification. C) Oxygen demand and consumption increase at the onset of labor because of the presence of uterine contractions. This client requires no further intervention. D) Polyuria is common during labor. This results from the increase in cardiac output, which causes an increase in the glomerular filtration rate and renal plasma flow, and requires no further intervention. Page Ref: 450

The 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) "Unless you have pain with urination, we don't need to worry about it." B) "These symptoms usually mean the baby's head has descended further." C) "Come in for an appointment today and we'll check everything out." D) "This might indicate that the baby is no longer in a head-down position."

Answer: B Explanation: A) Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection. B) This is the best response because it most directly addresses what the client has reported. C) There is no need for an additional appointment. D) The fetus's changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis. Page Ref: 440

A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? A) Second phase B) Latent phase C) Active phase D) Transition phase

Answer: B Explanation: A) There is no phase of labor that is identified as the second phase. B) In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions. C) When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. During this phase the cervix dilates from about 4 to 7 cm. D) When the woman enters the transition phase, she may demonstrate significant anxiety. She becomes acutely aware of the increasing force and intensity of the contractions. She may become restless, frequently changing position. Page Ref: 443

A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action? A) Determine who might be the father of the baby for paternity testing. B) Ask the client what kind of birthing experience she would like to have. C) Assess blood pressure and check for proteinuria. D) Obtain a Social Services referral to discuss adoption.

Answer: C Explanation: A) Paternity testing is a lower priority than the physiologic well-being of the client and fetus. B) A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences. C) Preeclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority. D) It would be inappropriate to discuss adoption or parenting during labor, especially with an adolescent who did not know she was pregnant prior to the onset of labor. The nurse should wait until after the birth to have this discussion. Page Ref: 523

Two hours after an epidural infusion has begun, a client complains of itching on her face and neck. What should the nurse do? A) Remove the epidural catheter and apply a Band-Aid to the injection site. B) Offer the client a cool cloth and let her know the itching is temporary. C) Recognize that this is a common side effect, and follow protocol for administration of Benadryl. D) Call the anesthesia care provider to re-dose the epidural catheter.

Answer: C Explanation: A) Removing the epidural catheter does not address the side effects of the medication. B) Using a cool cloth does not address the side effects of the medication. C) Itching is a side effect of the medication used for an epidural infusion. Benadryl, an antihistamine, can be administered to manage pruritus. D) The anesthesia care provider would not re-dose, as that would continue or worsen the side effects of the medication. Page Ref: 543

A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful? A) Talk to the client the entire time. B) Turn on the television to distract the client. C) Stand next to the bed with hands on the railing next to the client. D) Sit silently in the room away from the bed.

Answer: C Explanation: A) Talking might irritate the client. B) Turning on the television might irritate the client. C) Standing next to the bed is supportive without being irritating. The laboring woman fears being alone during labor. The woman's anxiety may be decreased when the nurse remains with her. D) Sitting silently away from the client can lead to her feeling abandoned. Page Ref: 527

A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do? A) Go to the nurse's station and immediately call the physician. B) Run to the delivery room for an emergency birth pack. C) Stay with the client and ask auxiliary personnel for assistance. D) Hold back the infant's head forcibly until the physician arrives for the delivery.

Answer: C Explanation: A) The nurse can direct auxiliary personnel to contact the physician. B) The nurse can direct auxiliary personnel to retrieve the emergency birth pack. C) If birth is imminent, the nurse must not leave the client alone. D) With one hand, the nurse should apply gentle pressure against the fetal head to maintain flexion and prevent it from popping out rapidly. The nurse does not hold the head back forcibly. Page Ref: 525

A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 c m dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? A) Latent phase B) Active phase C) Transition phase D) Fourth stage

Answer: C Explanation: A) This is not the latent phase; in the latent phase of labor, contractions are every 10-20 minutes, 15-20 seconds' duration progressing to every 5-7 minutes, and 30-40 seconds' duration. Dilatation is 1-3 c m. B) This is not the active phase; in the active phase of labor, contractions are every 2-3 minutes with a dilatation of 4-7 c m. C) The transition phase begins with 8 c m of dilatation, and is characterized by contractions that are closer and more intense. D) The fourth stage occurs after delivery of the placenta. Page Ref: 504

The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? A) True labor contractions begin in the back and sweep toward the front. B) False labor often feels like abdominal tightening, or "balling up." C) True labor can be diagnosed only if cervical change occurs. D) False labor contractions do not increase in intensity or duration.

Answer: C Explanation: A) Although this is a true statement, it is not the most important indication of true labor. B) Although this is a true statement, it is not the most important fact about false and true labor. C) Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilation. D) Although this is a true statement, it is not the most important fact about true and false labor. Page Ref: 440

A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor? A) Active B) Latent C) Transition D) Fourth

Answer: C Explanation: A) In the active phase, the woman dilates from 4 to 7 centimeters. B) The latent phase is the beginning of labor contractions and the cervix may be dilated 0 to 3 centimeters. C) The transition phase begins with 8 cm to 10 cm of dilation, and contractions become more frequent, are longer in duration, and increase in intensity. D) There is no fourth phase. The fourth stage occurs after delivery of the placenta. Page Ref: 444

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? A) Increased pulse B) Elevated blood pressure C) Muscle tension D) Increased respirations

Answer: C Explanation: A) Increased pulse is a manifestation of pain, but does not impede labor. B) Elevated blood pressure is a manifestation of pain, but does not impede labor. C) It is important for the woman to relax each part of her body. Be alert for signs of muscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process. D) Increased respiration is a manifestation of pain, but does not impede labor. Page Ref: 428

The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? A) Right-acromion-dorsal-anterior B) Right-sacrum-transverse C) Occiput anterior D) Posterior position

Answer: C Explanation: A) Right-acromion-dorsal-anterior denotes a fetal position in a shoulder presentation, which would be a difficult delivery. B) Right-sacrum-transverse indicates a breech delivery, which would be a difficult delivery. C) The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally. D) The fetal head presents a larger diameter in a posterior position than in an anterior position. A posterior position increases the pressure on the maternal sacral nerves, causing the laboring woman to experience backache and pelvic pressure. Page Ref: 436

The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? A) "In normal labor, as the uterine contractions become stronger, they usually also become less frequent." B) "In normal labor, as the uterine contractions become stronger, they usually also become less painful." C) "In normal labor, as the uterine contractions become stronger, they usually also become longer in duration." D) "In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration."

Answer: C Explanation: A) The uterine contractions of labor become more frequent as labor progresses. B) The uterine contractions of labor become more painful over time. C) During the active and transition phases, contractions become more frequent, are longer in duration, and increase in intensity. D) The uterine contractions of labor do not become shorter in duration as labor progresses. Page Ref: 444

The 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 shouldn't work so much at this point in pregnancy." B) "What you are describing is not commonly experienced in the last weeks." C) "Your body may be telling you it is going into labor soon." D) "If the bladder pressure continues, come in to the clinic tomorrow."

Answer: C Explanation: A) There is no indication that the client should decrease her work schedule. B) Lightening is a common and expected finding. C) One of the premonitory signs of labor is lightening: The fetus begins to settle into the pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing. D) Lightening does not indicate pathology, and therefore there is no need for the client to come to the clinic if the symptoms continue. Page Ref: 440

The nurse is assessing the emotional state of a client following the delivery of her newborn. Which response by the client requires further follow up by the nurse? A) Excitability B) Crying C) Quiet D) Withdrawn

Answer: D Explanation: A) The emotional response to birth varies, and excitability is considered a normal finding. B) The emotional response to birth varies, and crying is considered a normal finding. C) The emotional response to birth varies, and being quiet is considered a normal finding. D) Being withdrawn is not considered a normal emotional response to delivery of a newborn, and requires further follow up by the nurse. Page Ref: 519

The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply. A) Woman at 7 cm, fetus in general flexion B) Woman at 3 cm, fetus in longitudinal lie C) Woman at 4 cm, fetus with transverse lie D) Woman at 6 cm, fetus at -2 station, mild contractions E) Woman at 5 cm, fetal presenting part is right shoulder

Answer: C, D, E Explanation: A) Fetal attitude refers to the relation of the fetal body parts to one another and describes the posture the fetus assumes as it conforms to the shape of the uterine cavity. The normal attitude of thterm-0e fetus is termed general flexion, where the head is flexed so that the chin is on the chest with the arms crossed over the chest, and the legs are flexed at the knees with the thighs on the abdomen. B) Fetal lie refers to the relationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, or cephalocaudal, axis of the mother. The fetus may assume either a longitudinal (vertical) or a transverse (horizontal) lie; a longitudinal lie is normal. C) A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. D) Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. 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. E) When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part. Page Ref: 432

As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? A) Cultural background B) Plans for keeping the infant C) Support persons D) Developmental level

Answer: D Explanation: A) Cultural background is important to planning anyone's care. B) It is important to first determine the client's developmental level when planning nursing care for the mother who is keeping her infant. C) Support persons are important to planning anyone's care. D) Because her cognitive development is incomplete, the younger adolescent may have fewer problem-solving capabilities. The very young woman needs someone to rely on at all times during labor. She may be more childlike and dependent than older teens. Page Ref: 523

The nurse has presented a session on pain relief options to a prenatal class. Which statement indicates that additional teaching is needed? A) "An epidural can be continuous or can be given in one dose." B) "A spinal is usually used for a cesarean birth." C) "Pudendal blocks are effective when a vacuum is needed." D) "Local anesthetics provide good labor pain relief."

Answer: D Explanation: A) Epidurals can be given either as a bolus or as a continuous infusion. B) Spinals are anesthesia, and are commonly used for cesarean birth. C) The advantages of pudendal block are ease of administration and absence of maternal hypotension. It also allows the use of low forceps or vacuum extraction for birth. D) Local anesthetics are not used for labor pain relief. They are used prior to episiotomy and for laceration repair. Page Ref: 549

A client has just been admitted for labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The client wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the client understands which of the following? A) In order to respect her wishes, no medication will be given. B) Pain relief will allow a more enjoyable birth experience. C) The use of medications allows the client to rest and be less fatigued. D) Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

Answer: D Explanation: A) It is important to respect the client's wishes when possible. Once the effects are explained, it is still the client's choice whether to receive medication. B) That pain relief can lead to a more enjoyable experience might be the view of the nurse, but not of the mother. C) While pain relief can allow the mother to be less fatigued, that might not be the mother's first priority. D) The nurse can explain to the client that, although pharmacologic agents do affect the fetus, so does the pain and stress experienced by the laboring mother. If the woman's pain and anxiety are more than she can cope with, the adverse physiologic effects on the fetus may be as great as would occur with the administration of a small amount of an analgesic agent. Once the effects are explained, however, it is still the client's choice whether to receive medication. Page Ref: 530

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently? A) A full bladder impedes oxygen flow to the fetus. B) Frequent voiding prevents bruising of the bladder. C) Frequent voiding encourages sphincter control. D) A full bladder can impede fetal descent.

Answer: D Explanation: A) Oxygen flow to the fetus is not impacted by a full bladder. B) Frequent voiding has nothing to do with bruising of the bladder. C) Frequent voiding has nothing to do with sphincter control. D) The woman should be encouraged to void because a full bladder can interfere with fetal descent. If the woman is unable to void, catheterization may be necessary. Page Ref: 504

The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client? A) Encourage the client to vocalize during contractions. B) Perform vaginal exams only between contractions. C) Provide a C D of soft music with sounds of nature. D) Offer to teach the partner how to massage tense muscles.

Answer: D Explanation: A) Some clients want to vocalize during labor, and some vocalize only when they perceive that they are losing control. The client should determine whether vocalization is desirable for her. B) Vaginal exams are performed between contractions for all laboring clients in order to decrease discomfort. C) The nurse should ask the client what type of music she would like to listen to instead of making assumptions. D) Massage is helpful for many clients, especially during latent and active labor. Massage can increase relaxation and therefore decrease tension and pain. Page Ref: 508

A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? A) That a mild analgesic be administered B) An epidural C) A local anesthetic block D) Nonpharmacologic methods of pain relief

Answer: D Explanation: A) The client does not have an established labor pattern, and analgesics given for pain relief could prolong labor or stop the process. B) The client does not have an established labor pattern, and an epidural given for pain relief could prolong labor or stop the process. C) The pudendal block technique provides perineal anesthesia for the second stage of labor, birth, and episiotomy repair. D) For this pattern of labor, nonpharmacologic methods of pain relief should be suggested. These can include back rubs, providing encouragement, and clean linens. Page Ref: 529

During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? A) Turn the client onto her left side. B) Place the bed in Trendelenburg position. C) Massage the fundus. D) Continue to monitor.

Answer: D Explanation: A) A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. B) The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. C) The uterus should be midline and firm; massage is not necessary. D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia. Page Ref: 449

The charge nurse has received the shift change report. Which client requires immediate intervention? A) Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes B) Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation C) Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge D) Woman at 3 cm screaming in fear because her mother died during childbirth

Answer: D Explanation: A) Strong contractions every 3 minutes constitute an adequate labor pattern during induction of labor. This client is experiencing no complications. B) Longitudinal lie with cephalic presentation is a head-down position. This is expected. C) 10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected. D) This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority. Page Ref: 443

When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are what? A) Both are approximately the same size. B) Both close within 12 months of birth. C) Both are used in labor to identify station. D) Both allow for assessing the status of the newborn after birth.

Answer: D Explanation: A) The anterior fontanelle measures approximately 2-3 cm. The posterior fontanelle is much smaller. B) The anterior fontanelle closes around the 18th month. The posterior fontanelle closes between 8 and 12 weeks after birth. C) In labor, the presenting part, not the fontanelles, is used to identify station. D) The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth. Page Ref: 432

The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, 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) Encourage the client to have an epidural for pain. D) Reassure the client that she will not be left alone.

Answer: D Explanation: A) The client is in the transitional phase of the first stage of labor, and will not want to be alone. B) The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone. C) The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief. D) Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time. Page Ref: 444

The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? A) Weak B) Mild C) Moderate D) Strong

Answer: D Explanation: A) Weak contractions are not identified. B) If the uterine wall can be indented easily, the contraction is considered mild. C) Moderate intensity falls between these two ranges. When intensity is measured with an intrauterine catheter, the normal resting tonus (between contractions) is about 10 to 12 mmHg of pressure. During acme the intensity ranges from 25 to 40 mmHg in early labor, 50 to 70 mmHg in active labor, 80 to 100 mmHg during transition, and greater than 100 mmHg while the woman is pushing in the second stage. D) Strong intensity exists when the uterine wall cannot be indented. Page Ref: 437

The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? A) "I stimulated the top of the fetus's head to wake him up a little." B) "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." C) "I stimulated the top of the fetus's head to calm the fetus down before birth." D) "I stimulated the top of the fetus's head to find out whether he is in distress."

B) "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." Explanation: A) Waking the fetus is not the goal or outcome of fetal scalp stimulation. B) Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being. C) Calming the fetus is not the goal or outcome of fetal scalp stimulation. D) The nurse wants to assess what the fetus does with stimulation. Page Ref: 493

A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? A) "The most important part of fetal heart monitoring is the absence of variable decelerations." B) "The most important part of fetal heart monitoring is the presence of variability." C) "The most important part of fetal heart monitoring is the fetal heart rate baseline." D) "The most important part of fetal heart monitoring is the depth of decelerations."

B) "The most important part of fetal heart monitoring is the presence of variability." Explanation: A) Variable decelerations indicate cord compression. B) Baseline variability is a reliable indicator of fetal cardiac and neurologic function, and overall well-being. The opposing "push-pull" balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the FHR. C) The fetal heart rate baseline does not indicate central nervous system function. D) The depth of decelerations does not indicate central nervous system function. Page Ref: 484

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score? A) 7 B) 8 C) 9 D) 10

B) 8

The nurse determines that a newborn has the following findings: Heart rate: 88 beats per minute Respirations: 24 per minute and irregular Muscle tone: Minor movement of lower extremities Reflex response: Grimace Skin color: Pink body, blue extremities Using APGAR, which action should the nurse take at this time? A) Begin resuscitation B) Stimulate the infant C) Document the findings D) Nasopharyngeal suctioning

B) Stimulate the infantThe infant's Apgar score is 5. An Apgar score between 4 and 7 indicates the need for stimulation

A nurse is caring for a client who is 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A. Examine the amniotic fluid for meconium B. Check the FHR C. Dry the client and make them comfortable D. Apply a tocotransducer

B. Check the FHR The greatest risk to the client and fetus is umbilical for prolapse, leading to fetal distress following rupture of membranes. The first action to take is to check the FHR for clinical findings of distress

A nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios

B. Infection Rupture of membranes for longer than 24 hours prior to delivery increases the risk that infectious organisms will enter the vagina ad then eventually into the uterus

The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? A) "The monitor is necessary so we can see how your labor is progressing." B) "The monitor will prevent complications from the meconium in your fluid." C) "The monitor helps us to see how the baby is tolerating labor." D) "The monitor can be removed, and oxygen given instead."

C) "The monitor helps us to see how the baby is tolerating labor." Explanation: A) The fetal monitor does not help visualize labor progress. B) The fetal monitor does not prevent complications such as meconium aspiration syndrome. C) Electronic fetal monitoring (EFM) provides a continuous tracing of the fetal heart rate (FHR), allowing characteristics of the FHR to be observed and evaluated. D) Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Page Ref: 478

At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score? A) 7 B) 8 C) 9 D) 10

C) 9

The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? A) Late decelerations B) Early decelerations C) Accelerations D) Fetal dysrhythmia

C) Accelerations

The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? A) The client is assisted into supine position, and the position of the fetus is assessed. B) The upper portion of the uterus is palpated, then the middle section. C) After determining where the back is located, the cervix is assessed. D) Following voiding, the client's abdomen is palpated from top to bottom.

C) After determining where the back is located, the cervix is assessed. Explanation: A) Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation. B) This is the correct order of the first and second Leopold maneuvers C) The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers. D) The client is instructed to void prior to beginning Leopold maneuvers to enhance comfort. Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix. Page Ref: 473

The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? A) Blood pressure 120/88 B) Father a carrier of sickle-cell trait C) Dark red vaginal bleeding D) History of domestic abuse

C) Dark red vaginal bleeding Explanation: A) Although the diastolic reading is slightly elevated, this blood pressure reading is not the top priority. B) The infant also might have sickle-cell trait, but it is not life-threatening at this time. C) 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 mother and fetus. D) This client is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the client. Page Ref: 458

Persistent early decelerations are noted. What would the nurse's first action be? A) Turn the mother on her left side and give oxygen. B) Check for prolapsed cord. C) Do nothing. This is a benign pattern. D) Prepare for immediate forceps or cesarean delivery.

C) Do nothing. This is a benign pattern. Explanation: A) Early decelerations do not require any intervention. B) Early decelerations do not indicate a prolapsed cord. C) Early decelerations are considered benign, and do not require any intervention. D) Early decelerations do not warrant an immediate delivery. Page Ref: 487

The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? A) Early decelerations with each contraction B) Variable decelerations that recover to the baseline C) Late decelerations with minimal variability D) Accelerations

C) Late decelerations with minimal variability Explanation: A) Early decelerations are usually benign. B) Variable decelerations indicate cord compression, but those that recover to the baseline indicate that the fetus is tolerating the decelerations. C) Late decelerations are considered a non-reassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention. D) Accelerations of the fetal heart rate indicate good oxygen reserve. Page Ref: 488

After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? A) Increase the mother's oxygen rate. B) Turn the mother to the left lateral position. C) Prepare the mother for a higher-risk delivery. D) Increase the intravenous infusion rate.

C) Prepare the mother for a higher-risk delivery Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk

The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? A) Mild B) Moderate C) Strong D) Weak

C) Strong Explanation: A) The consistency of mild contractions is similar to that of the nose. B) The consistency of moderate contractions is similar to that of the chin. C) The consistency of strong contractions is similar to that of the forehead. D) Weak contractions are not identified. Page Ref: 470

A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? A) Change the client's position in bed. B) Notify the physician that birth is imminent. C) Administer oxygen at 2 liters per minute. D) Begin continuous fetal heart rate monitoring.

D) Begin continuous fetal heart rate monitoring Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring

After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? A) Breech presentation B) Uteroplacental insufficiency C) Compression of the fetal head D) Umbilical cord compression

D) Umbilical cord compression Variable decelerations occur when there is umbilical cord compression.