High Risk Intrapartum
A woman has received Prepidil (dinoprostone gel) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.
1
The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1. Late decelerations. 2. Hyperthermia. 3. Hypotension. 4. Early decelerations.
1
The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.
1
A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).
1 Calcium gluconate is the antidote for mag sulfate.
A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.
1, 4, and 5 are correct
A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sad. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.
1.
The nurse is admitting a 38-week-gestation client in labor. The nurse is unable to find the fetal heart beat with a Doppler. Which of the following comments by the nurse would indicate that the nurse is in denial? 1. "I'll keep trying until I find the heart beat." 2. "I am sure it is the machine. If I change the battery, I'm sure it will work." 3. "I am so sorry. I am not able to find your baby's heart beat." 4. "Sometimes I really hate these machines."
1.
A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.
1. A fetal heart check is the appropriate assessment. TEST-TAKING TIP: The clinical scenario is indicative of a placental abruption. Since the only oxygenation available to the fetus is via the placenta, the appropriate action by the nurse at this time is to determine the well-being of the fetus.
A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 millunits/min. 2. Assess fetal heart rate every 10 minutes. . 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.
1. An order for oxytocin administration should be questioned. Since the stem states that this woman has symptomatic placenta previa, the test taker can conclude that the woman is bleeding vaginally. It would be appropriate to monitor the fetal heart for any signs of distress, to weigh pads to determine the amount of blood loss, and to assess the hematocrit and hemoglobin to check for anemia. Labor, however, is contraindicated since vaginal delivery is contraindicated.
Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis. Margot Desevo;Desevo. Maternal and Newborn Success: A Course Review Applying Critical Thinking to Test Taking (Davis's Success Series) (Kindle Locations 5391-5392). Kindle Edition.
1. Fundal heights increase during pregnancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour. When a placenta abrupts, it separates from the uterine wall. As a result, a pool of blood appears behind the placenta. The pool of blood takes up space leading to an increase in the size of the uterus. The fundal height increases as the uterine size increases.
A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.
1. She's gonna have a c-section with anesthesia. needs to be taught to cough and deep breathe for the post-op period.
Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.
1. The first action the nurse should take is to place the woman in the knee chest position. The weight of the fetus on the prolapsed cord can rapidly result in fetal death. Therefore, the nurse must act quickly to relieve the pressure on the cord. Additional actions that can take pressure off the cord are placing the client in the Trendelenburg position and pushing the head off the cord with a gloved hand. This situation is an obstetric emergency.
A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diagnosis of acute oligohydramnios. The nurse must carefully observe this client for signs of which of the following? 1. Fetal distress. 2. Dehydration. 3. Oliguria. 4. Jaundice.
1. The nurse should carefully monitor the client for fetal distress
A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.
1. These are the classic signs of water intoxication. Clients who receive oxytocin over a long period of time are at high risk for water intoxication. The oxytocin molecule is similar in structure to the antidiuretic hormone (ADH) molecule. The body retains fluids in response to the medication much the same way it would in response to ADH. The nurse, therefore, should carefully monitor intake and output when clients are induced with oxytocin.
A woman, 32 weeks' gestation, contracting every 3 min X 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.
1. Urine output should be monitored. Max sulfate is excreted through the kidneys. If output drops, mag concentration levels rise in the blood stream.
A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? 1. Breech presentation. 2. Station +3. 3. Oligohydramnios. 4. Dilation 2 cm.
1. When a baby is in the breech presentation, there is increased risk of prolapsed cord. When babies are in the breech presentation, the cord sometimes slips past the baby and becomes the presenting part. The weight of the baby then compresses the cord, preventing the baby from being oxygenated. Additional situations that are at high risk for cord prolapse are hydramnios, premature rupture of membranes, and negative fetal station.
A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min X 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.
1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin Oxytocin stimulates the contractility of the uterine muscle. When the muscle is contracted, the blood flow to the placenta is reduced. Whenever there is evidence of fetal compromise and oxytocin is being infused, the intravenous should be stopped immediately in order to maximize placental perfusion.
The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? 1. Risk for impaired skin integrity. 2. Risk for body image disturbance. 3. Risk for impaired parenting. 4. Risk for ineffective sexuality pattern.
1. impaired skin integrity yo!
A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. . 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask.
1. multitask!
A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? 1. Fetal heart rate 210 bpm. 2. Maternal heart rate 60 bpm. 3. Early decelerations. 4. Beat-to-beat variability.
1. when FH >200 the medication should be stopped.
A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.
2
In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations.
2
A physician writes the following order-administer ampicillin 1 Gm IV q 4 h until delivery-for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacterium is sexually transmitted. 4. The bacterium causes puerperal sepsis.
2. Babies are susceptible to neonatal sepsis from vertical transmission of the bacteria
The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.
2. Green fluid and late decelerations are indicative of fetal distress.
A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1. 1.Contraction pattern is every 3 min X 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.
2. Late decelerations are indicative of uteroplacental insufficiency and indicate fetal distress
A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilatation and effacement. 4. Maternal pulse rate.
2. Maternal temperature is the highest priority. The test taker must remember that the uterine cavity is a sterile space while the vaginal vault is an unsterile space. When membranes have ruptured over 24 hours, there is potential for pathogens to ascend into the uterine cavity and infection to result. Elevated temperature is a sign of infection. .
During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her hips. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.
2. McRobert's maneuver YO!
In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations.
2. Remember pea-soup meconium is gross, and we don't want baby breathing that shit in.
Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor? 1. Client will be infection-free at discharge. 2. Client will exhibit normal breathing function at discharge. 3. Client will exhibit normal gastrointestinal function at discharge. 4. Client will void without pain at discharge.
2. The appropriate nursing care outcome is that the client survives and is breathing normally at discharge. At the time of placental separation or sometimes during stage 1 of labor, a small amount of amniotic fluid sometimes seeps into the mother's bloodstream via the chorionic villi. With the contraction of the uterus, the fluid is shunted into the peripheral circulation and forced into the woman's lung fields. If there is meconium or other foreign material in the fluid, the woman's prognosis declines. Women who experience forceful, rapid labors are especially at risk for this life-threatening complication.
A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4°F.
2. The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin be stopped. The test taker must determine which of the vital signs is unsafe in the presence of oxytocin. Oxytocin increases the contractility of the uterine muscle. When the muscle contracts, the blood supply to the fetus is diminished. A drop in fetal heart rate, therefore, is indicative of poor oxygenation to the fetus and is unsafe in the presence of oxytocin.
The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section: Risk for ineffective individual coping related to emergency procedure. Which of the following nursing interventions would be appropriate in relation to this diagnosis? 1. Apply antiembolic boots bilaterally. 2. Explain all procedures slowly and carefully. 3. Administer an antacid per MD orders. 4. Monitor the FH and maternal vital signs.
2. The nurse should explain it slowly.
A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.
2. The nurse should notify the health care practitioner of the client's request.
An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.
2. The nurse would expect bleeding
Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? 1. +3 pitting edema and pulmonary edema. 2. Epigastric pain and systemic jaundice. 3. +4 deep tendon reflexes and clonus. 4. Oliguria and elevated specific gravity.
2. both are reflective of hemolysis of red blood cells and of severe liver damage.
The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and head board. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.
2. eclamptic means she's had a seizure already... pad those rails!
The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick counts.
2. that's the swab they do that predicts preterm labor.
A 30-year-old G2P0010 in preterm labor is receiving nifedipine (Procardia). Which of the following maternal assessments noted by the nurse must be reported to the health care practitioner immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2000 cc.
3
A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days, "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman's bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman's uterus and monitor for ballottement.
3
When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a con- traction while another occurred 10 seconds after the contraction and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.
3
Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.
3
The labor nurse has just received shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 gm/dL. 2. G2PO101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. GIP0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2P1001, 39 weeks, Rh negative, today's hematocrit 31%.
3. A placental abruption is a life-threatening situation for the fetus. It has been 15 minutes since the fetal heart was assessed. This is the nurse's priority. TEST-TAKING TIP: In this question, the test taker must discriminate among four situations to discern which is the highest priority. Although a client with placenta previa is at high risk for bleeding, it is very likely that if she did start to bleed spontaneously that she would notify the nurse. The fetus of a client who has a placental abruption, however, is already in a life-threatening situation.
A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G3P0020, 17 years of age. 2. G4P2101, cancer survivor. 3. G5P1211, cocaine abuser. 4. G6P0323, 27 weeks' gestation.
3. Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruption. It is very important that the test taker not read into any question or response. In the preceding question, all four of the women have had complicated pregnancies. The test taker should not presume the cause of the complications when they are not stated but rather look for the answer that does absolutely place the client at high risk for the abruption.
A preterm labor client, 30 weeks' gestation who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."
3. DUH maturation of the fetal lung cells.
The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal warranting further sampling. 4. The results are within normal limits.
3. Further testing is indicated. Some practitioners perform fetal scalp sampling when there is a decrease in fetal heart variability. A normal fetal pH is defined as 7.25 to 7.35. An acidotic fetus has a pH that is less than 7.20. When the pH is between 7.20 to 7.25, the value is considered to be equivocal with a need for further testing. Usually interventions are instituted-oxygen applied, position changed, IV fluid increased-and another sampling is done in 10 to 15 minutes. Margot Desevo;Desevo. Maternal and Newborn Success: A Course Review Applying Critical Thinking to Test Taking (Davis's Success Series) (Kindle Locations 5697-5699). Kindle Edition.
Four women request to labor in the hospital bathtub. Which of the women is at in- creased risk from the procedure? 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with prolonged rupture of the membranes.
4
The health care practitioner performed an amniotomy 5 minutes ago on a client, G3P1011, 41 weeks' gestation, -4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is postterm. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.
3. It is likely that the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelerations are seen on the FH monitor
Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.
3. Low platelets are consistent with the DX of HELLP.
A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min X 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.
3. Mag sulfate is a tocolytic!
A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? 1. Prolonged labor. . 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta.
3. Placental abruption is associated with maternal illicit drug use. Crack cocaine is a powerful vasoconstrictive agent. The chorionic villi atrophy as a result of the vasoconstrictive effects of the drug. Placental abruption, when the placenta detaches from the decidual lining of the uterus, is therefore of particular concern.
Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 120 with variable decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta.
3. The drop in fetal heart rate with variable decelerations indicates that the cord has likely prolapsed. TEST TAKING TIP: The test taker must remember that variable decelerations are caused by cord compression. The fact that variables are seen in the scenario as well as a precipitous drop in the fetal heart baseline is an indirect indication that the cord is being compressed, resulting in decreased oxygenation to the fetus.
A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure. Margot Desevo;Desevo. Maternal and Newborn Success: A Course Review Applying Critical Thinking to Test Taking (Davis's Success Series) (Kindle Locations 5397-5398). Kindle Edition.
3. The most common difference between placenta previa and placental abruption is the absence or presence of abdominal pain.
A woman being induced with oxytocin (Pitocin) is contracting every 3 min X 30 seconds. Suddenly the woman becomes dypsneic, cyanotic, and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.
3. The nurse's priority action is to administer oxygen. TEST-TAKING TIP: This client is exhibiting the classic signs of an amniotic fluid embolism. At this point, the baby's health is secondary because the mother is in a life-threatening situation. The nurse must apply oxygen and call a code immediately.
A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous ampicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery.
3. Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG. TEST-TAKING TIP: Although this is a woman who is in labor, the nurse must anticipate the needs of the neonate after delivery. Since it is recommended that the baby receive the medication within a restricted time frame, it is especially important for the nurse to be proactive and obtain the physician's order.
A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1. Administer bethamethasone (Celestone) 12 mg IM daily times 2. Maintain strict bed rest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 cc/hr).
3. assessing cervical dilation should be questioned. with possible complete previa, the nurse could puncture the placenta!
A nurse is caring for a gravid client who is GI P0000, 35 weeks' gestation. Which of the following would warrant the nurse to notify the woman's health care practitioner that the client is in preterm labor? 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Contraction duration of 30 seconds.
3. dilation of 3cm is indicative of PTL.
A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 120 seconds. 4. Fetal heart rate 156 with early decelerations.
3. that's a long contraction. That baby is being deprived from O2 for too long.
A client is in active labor. Which of the following assessments would warrant immediate intervention? 1. Maternal PaCO7 of 40 mm Hg. 2. Alpha-fetoprotein values of 2 times normal. 3. 3 fetal heart accelerations during contractions. 4. Fetal scalp sampling pH of 7.19.
4. A fetal scalp pH of 7.19 is indicative of an acidotic fetus. The test taker must read all four responses before choosing the best response. Although "2" includes a value that is not normal, it does not describe a situation that requires the nurse to take immediate action. A fetal scalp sampling pH below 7.20, however, is of immediate concern.
Four women request to labor in the hospital bathtub. Which of the women is at increased risk from the procedure? 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with prolonged rupture of the membranes.
4. A woman with prolonged rupture of the membranes should be discouraged from laboring in the water bath. Hydrotherapy is an excellent complementary therapy for the laboring woman. The warm water is relaxing and many women find that their pain is minimized. Women with prolonged rupture of the membranes, however, are at high risk for intrauterine infection and, if they labor in the tub, pathogens can ascend into the uterine cavity more easily.
A woman, G3P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.
4. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated. TEST-TAKING TIP: If the client's practitioner is convinced that surgery is the only appropriate intervention, he or she could get a court order to mandate the woman to accept surgery. The nurse's role at this point, however, is to provide the client with care in a nonthreatening, compassionate manner. The nurse must acknowledge and accept the client's legal right to refuse the surgery.
Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.
4. DUH!
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.
4. Increasing the IV rate helps to improve perfusion to the placenta. Because the fetus is being oxygenated via the placenta, it is essential that in cases of fetal distress, the amount of oxygen perfusing the placenta be maximized. That requires high concentrations of oxygen being administered via mask, blood volume being increased by increasing the IV drip rate, and cardiac blood return being maximized by positioning the client in order to remove pressure from the aorta and the vena cava.
6. A woman, G3P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes X 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give her oxygen. 3. Change her position. 4. Monitor her labor.
4. It is appropriate to monitor the woman's labor. Even if the test taker were unfamiliar with a normal contraction pattern-as seen in the stem of the question-if he or she knew that the fetal heart pattern is normal, he or she could deduce the correct answer. Three of the responses infer that the nurse should take action because of a complication. Only "4" indicates that the nurse should continue monitoring the labor. In this situation, the one response that is different from the others is the correct answer.
A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures.
4. Seizures are bad m'kay.
A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 cc/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 gm/dL.
4. That is dangerously high. Mag sulfate is toxic above 7 gm/dl.
A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses should the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual smell." 3. "Your labor should start pretty soon." 4. "Have you felt the baby move since the membranes broke?"
4. The most important information is the health and well-being of the fetus. Fetal movement indicates that the baby is alive. TEST-TAKING TIP: There are two concerns in this scenario: the fact that the membranes just ruptured and the smell of the fluid. The nurse should, therefore, consider two possible problems: possible prolapsed cord, which may occur as a result of the rupture of the amniotic sac, and possible infection, which may be indicated by the smell. Normal fetal movement will give the nurse some confidence that the cord is not prolapsed. This is the first question that should be asked. Then, the client should be encouraged to go to the hospital to be assessed for possible infection and signs of labor.
A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.
4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency. Identifying the priority action is the most difficult thing that nurses must do. The nurse must determine which of the situations is most life threatening. Of the four choices above, prolapsed cord is life threatening to the fetus. None of the other situations, as stated in the question, is life threatening to either the mother or the fetus.
A nurse is monitoring a client who is receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make in order to prevent a serious complication related to the procedure? 1. Color of the amniotic fluid. 2. Maternal blood pressure. 3. Cervical effacement. 4. Uterine resting tone.
4. Worrying about fluid overload, and blowing out that uterus.
The nurse in the obstetrician's office is caring for four 25-week-gestation white prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? 1. 38-year-old registered nurse in an abusive relationship. 2. 32-year-old secretary whose first child was born at 42 weeks' gestation. 3. 26-year-old attorney whose baby has a two-vessel cord. 4. 20-year-old college student with a history of long menstrual periods.
1. she's over 35, and in an abusive relationship.
A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.
2
A full-term client, contracting every 15 min 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.
2
A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.
2
The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 120 seconds. 4. Attitude flexed.
2
The physician has ordered Prepidil (dinoprostone) for 4 gravidas at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. G1P0000 contracting every 20 minutes x 30 seconds. 4. G6P3202 with blood pressure 140/90 and pulse 92.
2
The nurse is admitting four full term primigravid clients to the labor and delivery unit. The nurse requests pre-cesarean section orders from the health care practitioner for which of the clients? The client who has: 1. cervical cerclage. 2. FH 156 with beat-to-beat variability. 3. Maternal blood pressure of 90/60. 4. Full effacement.
1. That means there is a stitch around the cervix, which is incompatible with vag birth.
A pregnant woman, G3P2002, had her two other children by cesarean section. Which of the following situations would mandate that this delivery also be by cesarean? 1. The woman refuses to have a regional anesthesia. 2. The woman is postdates with intact membranes. 3. The baby is in the occiput posterior position. 4. The previous uterine incisions were vertical.
4
A primigravid client received Prepidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place woman on her side. 4. Monitor for onset of labor.
4
There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3P0020, in active labor. 2. Age 22, G1P0000, eclampsia. 3. Age 25, G4P3003, last delivery by cesarean section. 4. Age 32, G2P0100, first baby died during labor.
3. A woman, no matter what age, who has had a previous cesarean section is at risk for uterine rupture. babies are birthed via cesarean section, the surgeon must create an incision through the uterine body. The muscles of the uterus have, therefore, been ligated and a scar has formed at the incision site. Scars are not elastic and do not contract and relax the way muscle tissue does. A vaginal birth after cesarean (VBAC) section can only be performed if the woman had a low flap (Pfannenstiel) incision in the uterus during her previous cesarean section. 15.
A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes + 1. 4. Blood pressure 140/90.
1. That lady has DIC!
During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? 1. Into the musculature of the buttock. 2. Through the urinary meatus. 3. Through the rectal sphincter. 4. Into the head of the clitoris.
3. That's DEEP!
A 40-week-gestation client has an admitting platelet count of 90,000 mm3 and a hematocrit of 29%. Her lab values 1 week earlier were platelet count 200,000 mm3 and hematocrit 37%. Which additional abnormal lab value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).
4. You'd expect to see an elevated ALT. Think HELLP!
