Exam 3 P3
The nurse is monitoring a client and notes: contractions every 2 to 3 minutes, duration 45 to 60 seconds, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?
second ✓
The nurse is giving discharge instructions to a client who experienced a complete spontaneous abortion. Which question should the nurse prioritize at this time?
"Do you have someone to talk to, or may I give you the names and numbers for some possible grief counselors?" ✓
The nurse is comforting and listening to a young couple who just suffered a miscarriage. When asked why this happened, which reason should the nurse share as a common cause?
Chromosomal abnormality ✓
The pregnant client and her partner have arrived for a scheduled cesarean delivery. Which action should the nurse prioritize?
Obtain laboratory specimens. ✓
The primigravida client is surprised by the continued uterine contractions while holding her new baby. Which explanation by the nurse will best explain these contractions?
Seals off the blood vessels at the site of the placenta ✓
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?
The frequency of the contractions is every 5 minutes. ✓
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?
Use a birthing ball and find a position of comfort. ✓
A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia instead of an epidural. Which medication will the nurse prepare to give the client first?
antacid ✓
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?
engagement ✓
The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation?
jugular distension ✓
The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize?
Help the woman change positions. ✓
The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started?
IV fluid bolus ✓
A pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records?
G3 T0 P2 A1 L2 ✓
The nurse is assessing a 37-year-old woman, pregnant with twins in her second trimester, and notes the following over the past 3 visits: blood pressure 128/88, 134/90, and 130/86. Which nutritional supplement should the nurse suggest the client take?
calcium ✓
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?
A dipstick value of 2+ for protein ✓
A pregnant client in her second trimester reports feeling tired all the time. The nurse notes pale skin and low normal hemoglobin on assessment. Which recommendation should the nurse prioritize for this client?
An iron supplement ✓
A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?
Anxiety can slow down labor and decrease oxygen to the fetus. ✓
The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize?
Assess return of sensory and motor functions to the lower extremities. ✓
The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure?
Baby developing postbirth jaundice ✓
The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize?
Be certain she is aware of potential complications. ✓
A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?
Before reporting to the RN, determine the uterine contraction pattern. ✓
A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?
Body secreting the excess fluids from pregnancy ✓
An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion but the cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action should the LPN prioritize?
Consult with the RN about offering the client a chance to speak with a psychiatrist. ✓
The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?
Continue this as long as she enjoys it. ✓
The nurse is assessing a 24-year-old pregnant client who reports excessive vaginal discharge that is messy and unpleasant but without a strong odor, itching, or irritation present. Which response should the nurse prioritize?
Use sanitary pads. ✓
The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize?
Take blood pressure and determine if clonus or edema are present. ✓
The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?
rubella ✓
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?
fetal position ✓
The nurse is assisting the health care provider with the pelvic assessment of a pregnant client. The nurse concludes that the obstetric conjugate will be how long if the distance between the symphysis pubis and sacral promontary is 13 cm?
13 cm
A 25-year-old client at 27 weeks' gestation reports waking up with leg cramps. Which suggestion should the nurse point out to the client to help relieve this discomfort?
Dorsiflex the foot while extending her leg during the cramp. ✓
The LPN/LVN is caring for a client who is scheduled for a cesarean delivery. The nurse points out to the client that during which stage of the process a different nurse will be the primary caregiver?
immediate postoperative ✓
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
inability to push ✓
The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus?
Facing the right anterior pelvic quadrant ✓
The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?
Maternal tachycardia and falling blood pressure ✓
The nurse advises a pregnant client to keep a small high-carbohydrate, low-fat snack at the bedside. The nurse should point out this will assist with which condition?
nausea and vomiting ✓
The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse will continue to monitor this client for which condition?
severe preeclampsia ✓
A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stablizing. The nurse notes on routine assessment the client sleeping, lying on her side and EFM showing gradually increasing baseline with late decelerations. Which action should the nurse prioritize?
Notify the primary care provider or RN STAT. ✓
A pregnant woman at 38 weeks' gestation is receiving care for preeclampsia and suddenly complains of sharp abdominal pain. Which action should the nurse prioritize if the nurse notes a firm, distended and painful abdomen and dark red vaginal bleeding?
Obtain a full set of vital signs. ✓
The nurse is educating a patient with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply.
Polyhydramnios ✓ Hypertension ✓ Increased risk of spontaneous abortion ✓
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?
"After birth it is easier to develop an infection in the urinary system; we need to see you today." ✓
The health care provider has determined a client should be admitted for induction of labor and begins the process with cervical ripening overnight. Which teaching should the nurse prioritize for the client and her partner when describing this procedure?
"The cervix needs to be soft and thinning to be induced for labor; this helps soften the cervix." ✓
The nurse is monitoring the client's vital signs and notes: 100.2 F (37.9 C), heart rate 82, respiratory rate 17, and blood pressure 124/78. What is the best response when the client's partner asks if she is getting sick?
"The fever may be due to the epidural." ✓
A client suffering a miscarriage at 12 weeks' gestations is very upset that the health care provider has ordered a D&C. How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation?
"This procedure is needed to adequately remove all the fetal tissue." ✓
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?
"Your primary care provider will order safe doses of your medication." ✓
A 17-year-old client arrives for an annual examination and reports no changes since the last exam; however, the nurse assesses a positive Chadwick sign, slightly enlarged uterus, and subsequent positive urine pregnancy test. Which task should the nurse prioritize to assist this client who is denying any possibility that she is pregnant?
Accepting the pregnancy ✓
A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?
Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications. ✓
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?
Ambulate only with assistance from the nurse or caregiver. ✓
A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action?
Ambulation ad lib ✓
The health care provider has ordered a cesarean delivery for an exhausted client who has been in labor for many hours with the fetus now showing increasing signs of distress. As the client and partner express disappointment in not having a natural birth (and anxiety in not knowing what will now happen), which response will the nurse prioritize?
Briefly describe what will be experienced, explain each procedure, and encourage the partner to participate. ✓
The nurse is monitoring a client who is in the second stage of labor, at 2+ station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?
Encourage her through the contractions, explaining why she cannot receive any pain medication. ✓
A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control?
Exercise ✓
A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?
Fetal movement felt by examiner ✓
The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client?
Further testing is required ✓
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize?
Help the client regain control of her breathing technique. ✓
An infant is born to a mother with gestational diabetes. Which long-term maternal complication is associated with this diagnosis?
Increased risk of development of type 2 diabetes ✓
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client?
Increasing fluid intake ✓
A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and alert the RN or health care provider?
Initial BP 100/70 mm Hg; current BP 140/90 mm Hg ✓
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending?
Palpate the area just above the symphysis pubis. ✓
The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy?
Polyhydramnios ✓
A client in her first trimester reports frequent urination and asks the nurse for suggestions. The nurse should teach the client that the urination is most likely related to which cause?
Pressure on the bladder from the uterus ✓
A woman dilated to 10 centimeters and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?
Pudendal block ✓
The nurse is conducting class for pregnant women on problems associated with infections seen in women during gestation. One mother tells the nurse that she has never had the chicken pox (varicella) and is worried she will contract it before she delivers. What would the nurse explain to this mother to ease her anxiety?
She can receive her varicella vaccine immediately after delivery, followed by a second dose at her 6-week postpartum visit. ✓
The nurse is preparing a client for an emergent cesarean delivery. Which action should the nurse prioritize?
Sign informed consent. ✓
The community nurse is preparing a presentation illustrating successful pregnancies for a health fair. Which component should the nurse prioritize as the most critical to ensure a positive psychological experience with the pregnancy by the mother?
Social support ✓
The nurse is monitoring a client at 41 weeks' gestation receiving IV oxytocin. Which action should the nurse prioritize if noticeable contractions are occurring every 2 minutes, lasting 60 to 90 seconds on the fetal monitor?
Stop the IV oxytocin infusion ✓
At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment the client is dilated to 4 cm with contractions every 1 minute and increased signs of fetal distress. What action should the nurse prioritize after noting the time is now 1200 hrs?
Stop the oxytocin infusion. ✓
A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?
Support the client's decision and call the obstetrician. ✓
The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting?
Watch it and report if heavy increase in bleeding. ✓
A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client?
With a pillow under her right hip ✓
The nursing instructor has finished leading a general discussion with a group of nursing students exploring the labor and birthing process. The instructor determines the session is successful when the students correctly state which goal should be a priority?
Work with the labor client to plan pain management options. ✓
A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lbs (43 kg), and has gained 25 lbs (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment?
cannot be determined ✓
A woman with a positive history of genital herpes is in active labor. Assessment reveals vesicles in the perineum area, membranes are ruptured, dilated 5 cm, and effaced 70%. The nurse should prepare the client for which type of birth?
cesarean ✓
A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?
chronic villus sampling ✓
The nurse is teaching a pregnant client some nonpharmacologic ways to handle common situations encountered during pregnancy. The nurse determines the session is successful when the client correctly chooses which condition that can be minimized if she avoids drinking fluids with her meals?
heartburn ✓
The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
involution ✓
The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient?
low sodium diet ✓
A 24-year-old client presents in labor. The nurse notes there is an order to administer RhoGAM after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?
prevent maternal D antibody formation. ✓
The nursing instructor is teaching a class on the various hormones necessary for a successful pregnancy and birthing process. The instructor determines the session is successful when the students correctly choose which hormone as being necessary after birth to ensure growth of the newborn?
prolactin ✓
A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. The nurse notes on assessment cool, clammy skin, confusion, and vital signs: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize?
rule out shock ✓
A nurse working at the local health district clinic assists numerous adolescents who become pregnant. Which factor will the nurse point out to each teen is crucial for a positive pregnancy outcome?
support network ✓