exam 3 cloned assessment

a nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. the nurse observes variable decelerations in the fetal heart rate on the monitor strip. which of the following is a correct interpretation of this finding? a. variable decelerations are due to umbilical cord compression b. variable decelerations are caused by uteroplacental insufficiency c. variable decelerations are a result of the administration of IV narcotic analgesics d. variable decelerations are related to fetal head compression

a

a nurse is assessing a client who received magnesium sulfate to treat preterm labor. which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider? a. respiratory depression b. facial flushing c. nausea d. drowsiness

a (Magnesium sulfate toxicity can cause life-threatening adverse effects, including respiratory and CNS depression. The nurse should report a respiratory rate slower than 12/min immediately to the provider and stop the infusion.)

a nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. which of the following interpretations of this finding should the nurse make? a. the presenting part is 1 cm above the ischial spines b. the presenting part is 1 cm below the ischial spines c. the cervix is 1 cm dilated d. the cervix is effaced 1 cm

a (Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.) (b-Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the presenting part is 1 cm below the ischia spines it would be documented as plus (+) 1.) (c-Rationale C. Dilation of the cervix is measured from closed to 10 cm. It is not documented in terms of minus 1.) (d-Effacement or thinning and shortening of the cervix is measured from 0 to 100%. It is not documented in terms of minus 1.)

a nurse is caring for a client who is in preterm labor at 32 weeks of gestation. the client asks the nurse, "will my baby be okay?" which of the following responses should the nurse offer? a. "you must be feeling scared and powerless" b. "everyone worries about her baby when she's in labor" c. "you pregnancy is advanced so your baby should be fine" d. "we have a neonatal unit here that's equipped to handle emergencies"

a (This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client.)

a nurse is caring for a client who is in the active phase of the first stage of labor. when monitoring the uterine contractions, which of the following findings should the nurse report to the provider? a. contractions lasting longer than 90 seconds b. contractions occurring every 3 to 5 min c. contractions are strong in intensity d. client reports feeling contractions in lower back

a (A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.) (b-In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min intervals. This is an expected finding.) (c-This is an expected finding in a client who is moving from the active to transition phase of the first stage of labor. It does not need to be reported to the provider.) (d-This is an expected finding in a client who is in true labor. As the labor progresses, the contractions radiate to the abdomen.)

a nurse is teaching a client about black cohosh. which of the following information sould the nurse include in the teaching? a. "black cohosh should not be taken during pregnancy" b. "black cohosh helps relieve headache pain" c. "black cohosh increases the risk for bleeding" d. "black cohosh is a stimulant"

a (Black cohosh has estrogenic properties and should not be taken during pregnancy.) (b-Black cohosh has no analgesic effect to relieve headache pain; however, feverfew is known to alleviate migraine headaches when taken prophylactically.) (c-Black cohosh does not affect bleeding time; however, garlic decreases platelet aggregation and can increase the risk for bleeding.) (d-Black cohosh does not act as a stimulant; however, ephedra acts as a stimulant and can increased heart rate and elevated blood pressure.)

a nurse receives report about assignned clients at the start of the shift. which of the following clients should the nurse plan to see first? a. a client who experienced a cesarean birth 4 hr ago and reports pain b. a client who has preeclampsia with a BP of 138/90 mm Hg c. a client who experienced a vaginal birth 24 hr ago and reports no bleeding d. a client who is scheduled for discharge following a laparoscopic tubal ligation

a (Using Maslow's hierarchy of needs, assessment of pain and meeting the physiological needs of a surgical client are the priority nursing actions.) (b-A BP of 138/90 mm Hg is an expected finding in a client who has mild preeclampsia and this client does not need to be seen first.) (c-A client who experienced a vaginal birth 24 hr ago and reports no bleeding is an expected finding and this client does not need to be seen first.) (d-A client who is scheduled for discharge following a laparoscopic tubal ligation does not need to be seen first.)

a nurse is caring for a client who experienced a vaginal delivery 12 hr ago. when palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? a. at the level of the umbilicus b. 2 cm above the umbilicus c. one fingerbreadth above the symphysis pubis d. to the right of the umbilicus

a (Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day.) (b-The position of the fundus 2 cm above the umbilicus is an indication of subinvolution.) (c-The uterus would be palpated at a position between the umbilicus and symphysis pubis in a client who is approximately 1 week postpartum.) (d-A uterine fundus that is deviated to the right or left of the umbilicus indicates the client has a full bladder.)

a nurse is caring for a client who is to undergo a biophysical profile. the client asks the nurse what is being evaluated during this test. which of the following should the nurse include? select all that apply a. fetal breathing b. fetal motion c. fetal neck translucency d. amniotic fluid volume e. fetal gender

a, b, d (a-A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume.) (b-A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume.) (d-A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume.) (c-Fetal neck, or nuchal translucency, also called NT screening, is a separate evaluation tool that can be performed using ultrasound.) (e-Fetal gender can be identified via ultrasound but is not included in a biophysical profile.)

a nurse is caring for a client who is at 28 weeks of gestation and recieved terbutaline. which of the following findings should the nurse expect? a. FHR 100/min b. weakened uterine contractions c. enhanced production of fetal lung surfactant d. maternal blood glucose 63 mg/dL

b

a nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. which of the following is the priority action by the nurse following the procedure? a. monitor the client's temperature b. assess the FHR c. assess the odor of the amniotic fluid d. provide clean, dry underpads

b

a nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. which of the following assessment findings should the nurse report to the provider first? a. expulsion of a blood-tinged mucous plug b. continuous contraction lasting 2 min c. pressure on the perineum causing the client to bear down d. expulsion of clear fluid from the vagina

b (A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.)

a nurse on the obstetric unit is caring for a client who experienced abruptio placentae. the nurse observes petechia and bleeding around the IV access site. the nurse should recognize that this client is at risk for which of the following complications? a. anaphylactoid syndrome of pregnancy b. disseminated intravascular coagulation c. preeclamsia d. peurperal infection

b (Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.) (a-Anaphylactoid syndrome of pregnancy, due to an amniotic fluid embolism, typically occurs within 30 min after birth and is manifested by sudden, acute onset of hypoxia, hypotension, cardiac arrest, and coagulopathy.) (c-Preeclampsia is typically seen in the antepartum period and is manifested by elevated blood pressure, hyperactive reflexes, proteinuria, and edema.) (d-Puerperal or postpartum infection is identified by the presence of a fever of 380 C (100.40 F) or higher on 2 consecutive days of the first 10 postpartum days and can include endometritis, wound infections, urinary tract infections, and mastitis.)

a nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. the bleeding started spontaneously in the morning and is not accompanied by contractions. the client is not in distress and she states that she can "feel the baby moving." an ultrasound is scheduled stat. the nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? a. fetal lung maturity b. location of the placenta c. viability of the fetus d. the biparietal diameter

b (Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.)

a nurse is caring for several clients. the nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? a. a client who is experiencing fetal death at 32 weeks of gestation b. a client who is experiencing preterm labor at 26 weeks of gestation c. a client who is experiencing braxton-hicks contractions at 36 weeks of gestation d. a client who has a post-term pregnancy at 42 weeks of gestation

b (Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks of gestation is a candidate for tocolytic therapy.)

a nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. which of the following is the priority action for the nurse to take? a. cut the umbilical cord b. apply perineal pressure to the emerging fetal head c. prevent the perineum from tearing d. promote delivery of the placenta

b (Using Maslow's hierarchy of needs, the priority intervention is to prevent injury to the fetus during the delivery by applying gentle perineal pressure to the emerging head. This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull due to a rapid delivery can cause neurologic damage (increased intracranial pressure and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations.)

a nurse is caring for a client during a nonstress test (NST). at the end of a 30-min period of observation, the nurse notes the following findings: the FHR baseline is 120/min with minimal variability and no accelerations. there are two decelerations of 15/min in the FHR during a period of fetal movement, each lasting 20 seconds. which of the following interpretations of these findings should the nurse make? a. a negative test b. a nonreactive test c. a positive test d. a reactive test

b (An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds.) (a-A negative test is one of the findings for a client having a contraction stress test (CST). This result indicates that at least three uterine contractions occurred in a 10-min period with no late or significant variable decelerations.) (c-A positive test is one of the findings for a client having a contraction stress test (CST). This result indicates that late decelerations occurred with 50% or more of the contractions, even if fewer than three contractions occurred in a 10-min period.) (d-An NST is interpreted as reactive if the fetus has a minimum of two accelerations in a 20-min period, each lasting at least 15 seconds and peaking at least 15/min above the FHR baseline.)

a nurse on a labor unit is admitting a client who reports painful contractions. the nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. the nurse obtains the following vital signs: FHR 130/min, maternal HR 128/min, and maternal BP 92/54 mm Hg. which of the following is the priority action for the nurse to take? a. notify the provider of the findings b. position the client with one hip elevated c. ask the client if she needs pain medication d. have the client void

b (Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.) (a-Calling the provider may be appropriate; however, this is not the priority intervention.) (c-The client's comfort should be addressed; however, this is not the priority intervention.) (d-The client should be encouraged to empty her bladder every 2 hr during labor; however, this is not the priority intervention.)

a nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. the baseline FHR is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. which of the following actions should the nurse take? a. decrease the rate of infusion of the maitenance IV solution b. discontinue the infusion of the IV oxytocin c. increase the rate of infusion of the oxytocin d. slow the client's rate of breathing

b (Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.) (a-Increasing the rate of infusion of the maintenance IV solution is an appropriate action to take when late decelerations occur.) (c-Increasing the rate of the oxytocin infusion can result in fetal distress due to uterine hyperstimulation.) (d-Oxygen should be administered at a rate of 8 to 10 L/min when late decelerations occur due to uterine hyperstimulation.)

a nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. the client is placed on a fetal monitor indicating a regular FHR of 138/min and no uterine contractions. the client's vital signs are: BP 98/52 mm HG, HR 118 BPM, RR 24/min, and temp 36.4 C (97.6 F). which of the following is the priority nursing action? a. insert an indwelling urinary catheter b. initiate IV access c. witness the signature for informed consent for surgery d. prepare the abdominal and perineal areas

b (Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.) (a-An indwelling urinary catheter can be inserted in the delivery room just prior to delivery. This is not the priority nursing action.) (c-Rationale C. This is not the nurse's priority action at this time. A family member can sign the consent form if needed.) (d-Skin preparation can be delayed until just prior to a cesarean delivery. This is no the priority nursing action.)

a nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. which of the following is the priority nursing action? a. elevate the client's legs b. position the client on her side c. administer oxygen via face mask d. increase the infusion rate of the IV fluid

b (Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.) (a-Elevating the client's legs might help relieve maternal hypertension, but there is a higher priority action.) (c-Administering oxygen can help increase the oxygen concentration of whatever blood does get to the placenta, but there is a higher priority action.) (d-Increasing the rate of fluid infusion is an appropriate intervention for late decelerations, but there is a higher priority action.)

a nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. the nurse should recognize this finding as an indication of which of the following conditions? a. abruptio placentae b. placenta previa c. precipitous labor d. threatened abortion

b (Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.) (a-Abruptio placentae classically presents with vaginal bleeding, abdominal pain, uterine tenderness, and contractions. In some cases the hemorrhage can remain concealed.) (c-Precipitous labor contractions are hypertonic and often tetanic in intensity.) (d-Symptoms of a threatened abortion include spotting of blood and possible mild uterine cramping prior to 20 weeks of gestation.)

a nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. which of the following actions should the nurse include in the plan of care? a. keep four side rails up while the client is in bed b. check the cervix prior to analgesic administration c. monitor the (FHR) every hour d. insert an indwelling urinary catheter

b (Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn.) (a-Raising side rails is not usually necessary during labor unless clients have received opioid or sedative medications. Many clients in labor prefer to walk to help their labor progress. Raising four rails restrains the client.) (c-Monitoring the FHR every hour is not frequent enough. Even for low-risk clients, most facilities' protocols require monitoring the FHR every 15 to 30 min while the client is in the first stage of labor and every 5 to 15 min in the second stage (as long as the FHR has reassuring characteristics). High-risk clients require more frequent monitoring.) (d-Inserting an indwelling urinary catheter is not generally necessary. The nurse should assess for bladder fullness, especially if the client has had epidural anesthesia. If the client is unable to urinate, a straight catheter will suffice in most instances.)

a nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. which of the following should the nurse identify as a sign that precedes labor? a. decreased vaginal discharge b. a surge of energy c. urinary retention d. weight gain of 0.5 to 1.5 kg

b (Prior to the onset of labor, the pregnant client experiences a surge of energy.) (a-Increased vaginal discharge is a result of congestion of vaginal mucous membranes.) (c-The return of urinary frequency precedes the onset of labor due to bladder pressure after lightening.) (d-A loss of 0.5 to 1.5 kg occurs before the onset of labor due to water loss.)

a nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. the client says she feels lightheaded and her fingers are tingling. which of the following actions should the nurse take? a. administer oxygen via nasal cannula b. assist the client to breathe into a paper bag c. have the client tuck her chin to her chest d. instruct the client to increase her respiratory rate to more than 42 breaths per min

b (This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.) (a-This client is experiencing respiratory alkalosis due to hyperventilation. She needs to rebreathe carbon dioxide to replace the bicarbonate ion rather than receive additional oxygen.) (c-This client is experiencing respiratory alkalosis due to hyperventilation. Having the client tuck her chin does not relieve this condition.) (d-This client is experiencing respiratory alkalosis due to hyperventilation. She needs to rebreathe carbon dioxide to replace the bicarbonate ion and should maintain a breathing rate of 32 to 40 breaths per minute.)

a nurse is admitting a client who has a diagnosis of preterm labor. the nurse anticipates a prescription by the provider for which of the following medication? select all that apply a. prostaglandin E2 b. indomethacin c. magnesium sulfate d. methylergonovine e. oxytocin

b, c (b-Indomethacin is used to relax uterine smooth muscles and suppress uterine activity in clients who have a diagnosis of preterm labor.) (c-Magnesium sulfate is a tocolytic and stops contractions in clients experiencing preterm labor.) (a-Prostaglandin E2 is used to stimulate cervical ripening and hasten the onset of labor.) (d-Methylergonovine promotes uterine contractions to manage postpartum hemorrhage.) (e-Oxytocin is used to induce and augment labor.)

a nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. the client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. the nurse should provide which of the following explanations? a. "It is used to stop preterm labor contractions." b. "It halts cervical dilation." c. "It promotes fetal lung maturity." d. "It increases the fetal heart rate."

c

a nurse is caring for a client who is having a nonstress test performed. the fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. which of the following actions should the nurse perform? a. immediately report the situation to the client's provider and prepare the client for induction of labor b. encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring c. offer the client a snack of orange juice and crackers d. turn the client onto her left side

c (A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement.)

a nurse receives report about a client who is in labor and is having contractions 4 min apart. which of the following patterns should the nurse expect on the fetal monitoring tracing? a. contractions that last for 60 seconds each with a 4-min rest between contractions b. a contraction that lasts 4 min followed by a period of relaxation c. contractions that last for 60 seconds each with a 3-min rest between contractions d. contractions that last 45 seconds each with a 3-min rest between contractions

c (A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.) (a-A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. This contraction interval is 5 min.) (b-A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. This pattern is longer than 4 min.) (d-A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. This contraction pattern is less than 4 min.)

a nurse is performing leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. which of the following fetal presentations should the nurse document in the client's medical record? a. vertex b. shoulder c. breech d. mentum

c (An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.) Fetal position is indicated by a three letter abbreviation. The first letter indicates the side of the maternal pelvis that the presenting part of the fetus is located. The second letter indicates the part of the fetus that is closest to the cervix. The third letter indicates whether the fetal presenting part is located in the anterior, posterior, or transverse portion of the maternal pelvis. (a-A vertex presentation indicates that the fetal head is the closest fetal part to the cervix. A letter "O" as the second letter in the abbreviation would indicate the fetal occiput was the presenting part.) (b-A shoulder as the presenting part is denoted as an "A" for the acromion process.) (d-A letter "M" as the second letter in the abbreviation would indicate the fetal chin was the presenting part. Mentum indicates that the fetus has fully extended its head and is presenting with its chin.)

a nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. the nurse determines that the client's oral temperature is 38.9 C (102 F). besides notifying the provider, which of the following is an appropriate nursing action? a. recheck the client's temperature in 4 hr b. administer glucocorticoids intramuscularly c. assess the odor of the amniotic fluid d. prepare the client for emergency cesarean section

c (Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid.) (a-The client's temperature should be checked at least every 2 hours after rupture of membranes.) (b-Antenatal glucocorticoids are indicated for all women between 24 and 34 weeks of gestation when preterm birth is threatened.) (d-While clients who have chorioamnionitis are more likely to have a dysfunctional labor, it is not an indication for an emergent cesarean section.)

a nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. the client asks why she is having an ultrasound prior to the procedure. which of the following is an appropriate response by the nurse? a. "this will determine if there is more than one fetus" b. "it is useful for estimating fetal age" c. "it assists in identifying the location of the placenta and fetus" d. "this is a screening tool for spina bifida"

c (Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.) (a-Although ultrasound might be used to assess the number of fetuses, this is not the purpose of an ultrasound prior to amniocentesis.) (b-Although ultrasound might be used to assess the age of the fetus, this is not the purpose of an ultrasound prior to amniocentesis.) (d-Although ultrasound might be used to assess the fetus for spina bifida, this is not the purpose of an ultrasound prior to amniocentesis.)

a nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. the fetus is at 1+ station, and the client's amniotic membranes are intact. the client suddenly states that she needs to push. which of the following actions should the nurse take? a. assist the client into a comfortable position b. observe the perineum for signs of crowning c. have the client pant during the next contractions d. help the client to the bathroom to void

c (Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.) (a-A comfortable position will not affect the client's need to push.) (b-At 7 cm of cervical dilation, it is too soon to observe for crowning.) (d-Emptying the bladder does not alter the client's urge to push.)

a nurse is caring for a client who is in labor. which of the following nursing actions reflects application of the gate control theory of pain? a. administer prescribed analgesic medication b. encourage the client to rest between contractions c. massage the client's back d. turn the client onto her left side

c (The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client's back focuses on neuromuscular and cognitive changes.) (a, b, d-The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Administering pain medication does not address this theory.)

a nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. the nurse should understand that this diagnosis means which of the following? a. the client is carrying more than one fetus b. there is an elevated level of AFP in the amniotic fluid c. an excessive amount of amniotic fluid is present d. the fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor

c.

a nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced HTN. suddenly, the client reports continuous abdominal pain and vaginal bleeding. the nurse should suspect which of the following complications? a. placenta previa b. prolapsed cord c. incompetent cervix d. abruptio placentae

d

a nurse is observing the EFHR monitor tracing for a client who is at 40 weeks of gestation and is in labor. the nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? a. early decelerations b. accelerations c. late decelerations d. variable decelerations

d

a nurse is caring to a client who is in labor and has an epidural anesthesia block. the client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. which of the following is the priority nursing action? a. elevate the client's legs b. monitor vital signs every 5 min c. notify the provider d. place the client in a lateral position

d (Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.) (a-The nurse should elevate the client's legs if there is no improvement in the blood pressure with the client in a lateral position, but this is not the priority nursing action.) (b-The client's vital signs should be monitored every 5 min, but this is not the priority nursing action.) (c-The provider should be notified, but this is not the priority nursing action.)

a nurse is caring for a client who is at 39 weeks of gestation and is in active labor. the nurse locates the fetal heart tones above the client's umbilicus at midline. the nurse should suspect that the fetus is in which of the following positions? a. cephalic b. transverse c. posterior d. frank breech

d (With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.) (a - With a cephalic presentation, the fetal heart is generally below the level of the client's umbilicus.) (b-With a transverse presentation, the fetal heart is generally below the level of the client's umbilicus.) (c-With a posterior presentation, the fetal heart is generally below the level of the client's umbilicus.)

a nurse is caring for a client who is at 40 weeks gestation and is in active labor. the client has 6 cm of cervical dilation and 100% cervical effacement. the nurse obtains the client's BP reading as 82/52 mm Hg. which of the following nursing interventions should the nurse perform? a. prepare for a cesarean birth b. assist the client to an upright position c. prepare for an immediate vaginal delivery d. assist the client to turn onto her side

d () (a-Unless late decelerations are noted during fetal monitoring, there is no need to prepare for a cesarean birth.) (b-Placing the client in an upright position is unlikely to improve her blood pressure significantly.) (c-Unless the fetus is exhibiting changes during fetal monitoring, indicating distress, there is no need to hasten delivery.)

a nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. the nurse caring for her suspects placenta previa. which of the following is an appropriate nursing action? a. examination to determine cervical status b. a magnesium sulfate infusion c. initiation of pushing d. preperation for cesarean birth

d (A cesarean birth is indicated for all clients who have a confirmed placenta previa.) (a-Vaginal exams are contraindicated in the presence of a placenta previa.) (b-Magnesium sulfate infusions are indicated for the treatment of preterm labor or the prevention of seizures in the preeclamptic client. The therapeutic action is smooth muscle relaxation.) (c-All clients with a confirmed placenta previa must deliver via cesarean section.)

a nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. which of the following is the priority nursing action? a. monitor vaginal bleeding b. administer glucocorticoids c. insert an IV catheter d. apply an external fetal monitor

d (Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress.) (a-The quantity of vaginal bleeding and any associated pain should be monitored, but this is not the priority action by the nurse.) (b-Glucocorticoids should be administered to the client who is at less than 34 weeks of gestation to promote fetal lung maturity, but this is not the priority action by the nurse.) (c-IV access should be established, but this is not the priority action by the nurse.)

a nurse in a prenatal clinic is caring for a client. using leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. in which abdominal quadrant should the nurse expect to auscultate fetal heart tones? a. left lower b. right lower c. left upper d. right upper

d (Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.) (a-This is an incorrect response. Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be above the maternal umbilicus.) (b-This is an incorrect response. Fetal heart tones are best auscultated directly over the location of the fetal back which, in this breech presentation, would be above the maternal umbilicus.) (c-This is an incorrect response. Fetal heart tones are best auscultated directly over the location of the fetal back.)

a nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. which of the following is the priority nursing assessment for this client? a. temperature b. FHR c. bowel sounds d. respiratory rate

d (Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate.)

a nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. which of the following is the correct interpretation of this clinical finding? a. the fetal head is in the left occiput posterior position b. the largest fetal diameter has passed through the pelvic outlet c. the posterior fontanel is palpable d. the lowermost portion of the fetus is at the level of the ischial spines

d (The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.) (a-This describes a reference point of the fetal head in relation to the maternal pelvis, indicating a vertex presentation with the fetus in an attitude of general flexion.) (b-The pelvic outlet is the lower border of the true pelvis. When the largest fetal diameter has passed through the outlet, the station is greater than zero.) (c-This is a clinical finding indicating that the fetal lie is longitudinal with the fetus in an attitude of general flexion.)

a nurse is caring for a client who is in the first stage of labor. the nurse observes the umbilical cord protruding from the vagina. which of the following actions should the nurse perform first? a. cover the cord with a sterile, moist saline dressing b. prepare the client for an immediate birth c. place the client in knee-chest position d. insert a gloved hand into the vagina to relieve pressure on the cord

d (This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.) (a-While this is appropriate, it is not the first action the nurse should take.) (b-Although an emergency vaginal or cesarean birth might be necessary to deliver the fetus safely, this is not the first action the nurse should take.) (c-Although this is appropriate, it is not the first action the nurse should take.)

a nurse is caring for a client who is in active labor when the client's membranes rupture. the fetal monitor tracing shows late decelerations. which of the following actions should the nurse take first? a. palpate the client's uterus b. administer oxygen to the client c. increase the client's IV fluid infusion rate d. turn the client onto her side

d (When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin administration, or several other complicating factors. The client might be exerting pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.) (a-The nurse should palpate the client's uterus to check for tachysystole. However, another action is the priority.) (b-The nurse should administer oxygen at 8 to 10 L/min by nonrebreather facemask to enhance placental perfusion. However, another action is the priority.) (c-The nurse should increase the client's IV fluid infusion rate to increase circulating fluid volume. However, another action is the priority.)

a. b. c. d.

() (a-) (b-) (c-) (d-)

a nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. the client states that she is disappointed that she did not have natural childbirth. which of the following responses should the nurse make? a. "it sounds like you are feeling sad that things didn't go as planned" b. "at least you know you have a healthy baby" c. "maybe next time you can have a vaginal delivery" d. "you can resume sexual relations sooner than if you had delivered vaginally"

a