Intrapardum NCLEX
A nurse is caring for a patient who is in labor and who needs fetal heart monitoring. Which of the following is considered a non-reassuring sign seen during fetal heart rate monitoring? Select all that apply. -A change in fetal heart rate that is inconsistent with contractions -A deceleration in fetal heart rate that ends when the contraction does -A sustained fetal heart rate that does not vary with contractions -A deceleration in fetal heart rate that starts and ends after the contraction does -An acceleration in fetal heart rate during uterine contractions
Rationale: "A deceleration in fetal heart rate that starts and ends after the contraction does", "A change in fetal heart rate that is inconsistent with contractions", and "A sustained fetal heart rate that does not vary with contractions" are correct. The fetal heart rate changes during labor and delivery. An increase in rate is often a reassuring sign, but a decrease in rate can be non-reassuring, depending on whether it starts or stops in associated with contractions. Late decelerations start and end well after the contraction begins and ends, and is a non-reassuring sign of uteroplacental insufficiency. Variable decelerations are a non-reassuring sign in which inconsistent decelerations change with the onset and relief of cord compression. When the fetal heart rate does not vary with contractions, it is a non-reassuring sign that occurs due to fetal hypoxemia, acidosis, or some medications. "An acceleration in fetal heart rate during uterine contractions" is incorrect, because this is a usually a reassuring sign of a responsive fetus. "A deceleration in fetal heart rate that ends when the contraction does" is incorrect, because this describes an early deceleration, which occurs when the fetal head presses against the mother's soft tissues or pelvis during a contraction. This does not require any intervention.
A pregnant client is in labor and the nurse is helping to deliver her baby. During delivery, the client experiences shortness of breath, hypotension, and altered mental status. Which action should the nurse perform first? -Start chest compressions and CPR -Administer 100 percent oxygen via facemask -Set up for emergency cesarean section -Turn the client onto her left side
Rationale: "Administer 100 percent oxygen via facemask" is correct. The client in this situation is demonstrating signs of an amniotic embolism, which is a rare but life-threatening complication that can develop during labor. The nurse's first action is to help the client continue to breathe, which involves administration of oxygen first, then repositioning for better chest and lung expansion. "Turn the client onto her left side" is incorrect. First, oxygen. Then, position the mother on her side and prepare for intubation and emergency delivery. "Start chest compressions and CPR" is incorrect. The embolism affects the pulmonary system, not the cardiac system, so compressions and CPR are not utilized. "Set up for emergency cesarean section" is incorrect. After oxygen has been adminstered and the mother is positioned on her side, she is then prepared for intubation and emergency c-section.
A nurse is caring for a pregnant client who is in labor. Which of the following best describes interventions the nurse should perform during the third stage of labor? Select all that apply. -Administer uterotonics as ordered to prevent bleeding -Administer pain medications as needed -Assist the client to void every two hours -Observe for crowning when the fetal head reaches the perineum -Monitor for bleeding and placental separation
Rationale: "Administer pain medications as needed", "Monitor for bleeding and placental separation", and "Administer uterotonics as ordered to prevent bleeding" are correct. The third stage of labor occurs when the mother has already delivered the baby and is now delivering the placenta. In this case, the nurse should administer pain medication, as the mother may still be in pain with labor for placental delivery. The nurse should also monitor for bleeding and delivery of the placenta and ensure that the mother's uterus is contracting and becoming firm as expected to prevent bleeding. "Observe for crowning when the fetal head reaches the perineum" is incorrect. This occurs in the second stage of labor. "Assist the client to void every two hours" is incorrect, because this is an intervention done in the first stage of labor.
A nurse is caring for a pregnant client who is in labor. The nurse has applied an external fetal monitor to check the baby's heart rhythm. The nurse notes that the baby is having periodic, spontaneous accelerations in heart rate. Which action would the nurse perform in response? -Raise the head of the client's bed and offer ice chips -Turn off the oxytocin in the IV -Administer magnesium sulfate, as ordered -Continue to monitor and document changes
Rationale: "Continue to monitor and document changes" is correct. Fetal monitoring is designed to show the changes in fetal heart patterns during labor. Accelerations in fetal heart rate during labor are usually considered to be a reassuring sign that the baby is responding. The nurse should continue to monitor and document any changes that occur. "Turn off the oxytocin in the IV" is incorrect. There is no need to turn off oxytocin if there are spontaneous fetal heart rate accelerations because this is a normal occurrence for a healthy fetus. "Administer magnesium sulfate, as ordered" is incorrect. This is given to treat preterm labor, and would not be given in this scenario. "Raise the head of the client's bed and offer ice chips" is incorrect. These actions are comfort measures the nurse can take for the laboring mother, but are not necessary interventions in response to spontaneous accelerations in fetal heart rate.
A nurse who works on the postpartum unit is caring for a client who delivered a baby by cesarean section three hours ago. The mother has an epidural in place and is unable to get out of bed. Which information must be reinforced to this parent that would protect the safety of both the mother and the baby in this situation? -Avoid getting out of bed when the baby is not in the room -Do not change the baby's diaper unless the nurse is present -Do not leave the baby in her crib when she is out of arm's reach -Avoid using pain medications while the baby is in the room
Rationale: "Do not leave the baby in her crib when she is out of arm's reach" is correct. A postpartum client who had an epidural for a cesarean section will most likely have little pain or feeling below the waist due to the anesthetic medication being delivered through the catheter. If the client cannot get out of bed without help, the baby should not be left in the crib out of reach of the mother because if something were to happen to the baby, the mother would not be able to get to the baby without help. "Do not change the baby's diaper unless the nurse is present" is incorrect. As long as supplies are within reach, an epidural will not affect a mother's ability to change a diaper. "Avoid getting out of bed when the baby is not in the room" is incorrect, because the mother should avoid getting out of bed under any circumstance as long as the epidural catheter is in place. Whether or not the baby is in the room is not relevant. "Avoid using pain medications while the baby is in the room" is incorrect. Whether or not the baby is in the room is not related to the mother receiving pain medications.
While checking a fetal heart rate (FHR) on a pregnant client who is in labor, a nurse notes that the fetal heart rate slows below the baseline each time the mother has a contraction. By the end of the contraction, the FHR has returned to a normal rate. Which of the following best describes this phenomenon? -Early deceleration -Variable deceleration -Fetal bradycardia -Late deceleration
Rationale: "Early deceleration" is correct. The situation described indicates that the FHR is in an early deceleration pattern. This may occur when the fetal head is compressed against the birth canal or when there is excess pressure on the uterine fundus. It may also occur during a vaginal exam during labor. Typically, no intervention is required for an early deceleration. "Variable deceleration" is incorrect. A variable deceleration has a variable shape, duration, and degree of decline below baseline. It indicates cord compression, and the nurse should change the position of the mother, assess vital signs and possibly administer oxygen if this occurs. "Late deceleration" is incorrect. A late deceleration is a nonreassuring pattern that begins after the contraction begins and returns to baseline after the contraction ends. The nurse must focus on interventions that immediately improve placental blood flow and oxygenation of the baby. "Fetal bradycardia" is incorrect. Fetal bradycardia is a nonreassuring pattern in which the mother's position should be changed, oxygen administered to the mother, and preparations for cesarean delivery made.
A nurse is caring for a client who is in labor. The nurse has applied external fetal monitoring and notes that the baby's heart rate is having late decelerations. Which of the following actions should the nurse perform? Select all that apply. -Turn the client on her left side -Decrease the rate of IV fluids -Give oxygen to the mother -Monitor the mother's blood pressure for signs of hypotension -Notify the provider
Rationale: "Give oxygen to the mother", "Turn the client on her left side", "Monitor the mother's blood pressure for signs of hypotension", and "Notify the provider" are correct. Late decelerations are a non-reassuring fetal heart pattern that indicate that the baby is in distress. When the nurse notes this pattern on the monitor, interventions include administering oxygen to the mother to increase oxygen delivery to the baby, maintain client position on the left side, increase IV fluids, and notify the provider. Additionally, the nurse should check progress of labor by assessing cervical dilation. "Decrease the rate of IV fluids" is incorrect. Rather, IV fluids should be increased to maintain hydration and adequate maternal blood pressure.
A pregnant client comes into the hospital in active labor; the nurse notes that her contractions are less than one minute apart. Which of the following interventions should the nurse include to manage precipitous labor? -Check the dilation of the client's cervix -Instruct the client to pant if she feels the urge to push -Take a sample of fluid to determine if it is amniotic fluid or urine -Perform Leopold's maneuver to turn the baby
Rationale: "Instruct the client to pant if she feels the urge to push" is correct. Precipitous labor is considered to be labor and birth that takes less than three hours from beginning to end. A mother may deliver her baby very quickly in this situation, whether or not the provider is present. The nurse should instruct the mother to blow or to pant if she feels the urge to push, in order to buy a few extra minutes for the provider to arrive. The nurse should also set up for delivery and prepare to deliver the baby herself if the labor cannot be stopped. "Take a sample of fluid to determine if it is amniotic fluid or urine" is incorrect. Interventions during precipitous labor center on safe delivery of the baby. A fluid sample would not be necessary at this time. "Check the dilation of the client's cervix" is incorrect. The client is imminently close to delivering the baby, and checking the cervix could cause the delivery to occur even more rapidly. The nurse can best support the mother by encouraging her to relax and breathe through contractions. "Perform Leopold's maneuver to turn the baby" is incorrect. Leopold's maneuver is a way of determining the position of the baby inside the mother's uterus,. If necessary to deliver the baby before the provider arrives, the nurse will utilize the Ritgen maneuver, in which gentle pressure is applied to the fetal head upward to prevent damage to the baby's head and vaginal tearing.
A nurse is caring for a pregnant client who is in labor. The nurse places an external fetal monitor on the client's abdomen to assess fetal heart tones. While checking the client to determine cervical dilation, the nurse notes that the FHR increases above the baseline and then returns to normal levels after the exam. Which of the following responses from the nurse is most appropriate? -Provide supplemental oxygen and check the mother's heart rate -Assist the mother to lie on her side -Note the acceleration and continue to monitor -Increase the rate of oxytocin in the IV
Rationale: "Note the acceleration and continue to monitor" is correct. External fetal monitoring allows the nurse to follow the fetal heart rate while a mother is in labor. In a situation where the fetal heart rate increases above normal during an exam and then returns to baseline afterward, the fetal heart rate is accelerating, which is considered normal. The nurse should note the acceleration and continue to monitor. "Assist the mother to lie on her side" is incorrect. While the mother is allowed to lie on her side, it is not clinically indicated based on the question. "Increase the rate of oxytocin in the IV" is incorrect. Oxytocin is increased for labor augmentation, and is not done when the fetal heart rate accelerates with stimulation. "Provide supplemental oxygen and check the mother's heart rate" is incorrect. The question does not indicate that the mother or baby is lacking oxygen, so providing supplemental oxygen is not indicated.
Which of the following conditions would most likely cause vaginal bleeding during the third trimester of pregnancy? -Gestational trophoblastic disease -Placenta previa -Spontaneous abortion -Ectopic pregnancy
Rationale: "Placenta previa" is correct. Bleeding during pregnancy is always considered abnormal. A pregnant woman who experiences bleeding during the third trimester may be at risk of complications that can pose some risks to herself and her unborn baby. During the third trimester, vaginal bleeding is usually caused by such factors as preterm labor, placenta previa, or a placental abruption. "Ectopic pregnancy" is incorrect. Bleeding from an ectopic pregnancy occurs early due to the location of the fertilized egg in the fallopian tube. An ectopic pregnancy would never exist into the third trimester. "Spontaneous abortion" is incorrect. This refers to a miscarriage, which can occur before the 20th week of gestation. "Gestational trophoblastic disease" is incorrect, as this refers to a group of conditions in which tumors grow in the uterus.
A pregnant patient who is in labor has an epidural placed because she will be undergoing a cesarean section. The epidural remains in place for the next 24 hours after delivery. Which of the listed side effects is most commonly associated with an epidural following cesarean section? -Fever -Pruritus -Pulmonary embolism -Abdominal pain
Rationale: "Pruritis" is correct. Epidural anesthesia is a common form of pain control during labor and delivery. When an epidural is left in place after a procedure, such as a cesarean section, the mother may develop severe itching from the anesthetic. The pruritus often remains as long as the anesthetic is in the body system, but can be controlled with benadryl or other anti-itch medications. "Abdominal pain" is incorrect because the epidural will relieve pain rather than cause it. "Fever" is incorrect because fever is caused by infection, not epidural anesthetic. "Pulmonary embolism" is incorrect, as a pulmonary embolism (PE) is caused by blood clots and epidural anesthesia is not associated with an increased risk of blood clots.
A pregnant client is preparing to have a cesarean section to deliver her baby. The provider ordered for placement of an epidural for the procedure. What information should the nurse include about this type of anesthesia when teaching this client? Select all that apply. -The medication is delivered into the space outside the spinal cord -The client will be unconscious during the procedure -The epidural may cause hypertension -The epidural catheter is usually discontinued immediately following surgery -The epidural will relieve contraction pain and numb the perineum
Rationale: "The epidural will relieve contraction pain and numb the perineum" and "The medication is delivered into the space outside the spinal cord" are correct. An epidural may be used for clients undergoing cesarean section. The process involves insertion of a catheter and injection of medication into the epidural space next to the spine. When anesthesia is used, the client cannot feel anything from the point of insertion down. This method is used during cesarean section so the client can remain awake during the procedure. "The client will be unconscious during the procedure" is incorrect. The client is numb from the insertion point down, but remains fully awake during the entire procedure. "The epidural may cause hypertension" is incorrect. Epidurals can cause hypotension and bladder distension, so the nurse will monitor and treat for these conditions by administering IV fluids for hypotension and addressing the bladder distention after the procedure is complete. "The epidural catheter is usually discontinued immediately following surgery" is incorrect. The epidural catheter remains in place for an hour or two following the birth of the baby.
A nurse is caring for a client who had an episiotomy during her vaginal delivery. Which intervention would be most appropriate when caring for a client with this condition? -Apply a heating pad to the perineum for comfort -Administer an enema to prevent constipation -Help the client to sit on a donut pillow -Use clean technique for perineal care
Rationale: "Use clean technique for perineal care" is correct. An episiotomy is an incision made to enlarge the vaginal canal for the baby to pass through. Use of episiotomy procedures is not as common as in the past, but the nurse may still encounter this situation with a client. It is very painful for a postpartum patient. Nursing interventions for the post-episiotomy client center on pain relief, keeping the area clean, and monitoring for infection. Ice, sitz baths after the first 24 hours, pain medications, clean technique with perineal care, showers instead of baths and applying the perineal pad without touching the inside of the pad are all measures the nurse can take to assist the client. "Help the client to sit on a donut pillow" is incorrect because this increases the pressure on the incision site. "Administer an enema to prevent constipation" is incorrect because an enema is not indicated after an episiotomy due to trauma to the site. "Apply a heating pad to the perineum for comfort" is incorrect. Heat promotes the proliferation of bacteria, and the incision site is vulnerable to infection, especially in the perineum. Ice is encouraged, but not heat.
A pregnant patient who is 32 weeks' gestation is experiencing preterm labor and has been brought in to the hospital. Which of the following interventions are appropriate for the management of preterm labor? Select all that apply. -Maintain bed rest with the patient on her side -Monitor the fetal heart rate -Elevating the head of the bed and keeping the patient in a supine position -Evaluate for signs of infectionAdminister fluids
Rationale: -"Administer fluids", "Maintain bed rest with the patient on her side", "Monitor the fetal heart rate" and "Evaluate for signs of infection" are correct. Preterm labor occurs between 20 weeks and 37 weeks' gestation. Risk factors include multifetal pregnancy, age younger than 18 years, age greater than 40 years and first pregnancy, substance abuse, a history of medical conditions and infection. The interventions for preterm labor focus on stopping the labor. The nurse monitors for infection, monitors fetal status, restricts the patient's activity and ensures hydration. Medications may be administered as well. -"Elevating the head of the bed and keeping the patient in a supine position" is incorrect because this position puts downward pressure on the fetus, which could have an effect of preterm labor progression. The patient should maintain a lateral position.
A pregnant woman approaches a nurse in the hospital and asks for help. She states "My water broke and it feels like the baby is coming right now!" What actions should the nurse perform in response? Select all that apply. -Use an available blanket or towel to place under the patient's hips -Give the patient privacy by stepping away -Assist the patient to lie in the cleanest area possible -Direct the patient's spouse to the waiting area -Stay with the patient and call for help
Rationale: -"Stay with the patient and call for help", "Assist the patient to lie in the cleanest area possible" and "Use an available blanket or towel to place under the patient's hips" are correct. A precipitous delivery is one in which a baby is delivered much faster than anticipated. If the nurse must assist with a precipitous delivery, she should stay with the mother and call for help. The nurse should assist the mother to a clean, dry location and assist with delivering the baby until help arrives, placing a clean towel, blanket or similar protection under the patient's hips for the delivery. -"Give the patient privacy by stepping away" is incorrect because this is a medical emergency and the woman cannot be left unattended. -"Direct the patient's spouse to the waiting area" is incorrect because, unless the woman specifically requests that the spouse leave, they should stay to assist the nurse in whatever way possible.
A nurse is caring for a client and is checking fetal heart tones using a Doppler stethoscope. Which of the following interventions would the nurse employ during this process? Select all that apply. -Attach the Doppler connection to the forehead to stabilize the piece -Place the Doppler to the right side of the patient's midline -Press firmly on the abdomen and maintain the Doppler in the same position -Apply water-soluble gel to the patient's abdomen -Perform Leopold's maneuvers to determine fetal lie if the patient is more than 32 weeks' gestation
Rationale: A Doppler stethoscope assesses fetal heart tones through an ultrasonic method in which the nurse is able to hear the fetal heart sounds. The nurse applies gel for the Doppler to the patient's abdomen prior to starting. The nurse may need to perform Leopold's maneuvers to determine fetal lie with the procedure.
A nurse is caring for a patient who is in labor at the hospital. The nurse prepares to apply an external fetal monitor but the patient is morbidly obese and the monitor does not fit well. What should the nurse do? Select all that apply. -Perform a cervical check -Apply an intrauterine pressure catheter -Remove the monitor if it does not fit and provide reliable readings -Increase the amount of oxytocin and monitor the mother's contractions -Assist the client to lie on her side for monitoring
Rationale: A morbidly obese patient who is in labor may not be able to wear an external fetal monitor if there is significant abdominal fat tissue present. If the nurse cannot apply the external fetal monitor, she may use an intrauterine pressure catheter, which is inserted into the uterus after membranes have ruptured to assess the intensity of contractions.
A postpartum patient is recovering from a cesarean section in which she had an epidural placed for pain control. Following removal of the epidural, the patient develops a severe headache when she sits up in bed. The physician has instructed the patient that she will need a blood patch. Which best describes this procedure? -Placement of a large bandage over the site of the epidural insertion -Removing blood from a vein in the patient and injecting it into the epidural space in the back -Placement of a nerve block in the spinal column at the location of the affected epidural space -Replacement of the epidural catheter into the same space for long-term control
Rationale: An epidural involves placing a catheter into the epidural space of the spine to provide pain control. Occasionally, cerebrospinal fluid may leak out of the space after the catheter is removed, causing a severe headache in the patient. A blood patch can be performed by a physician to close the site and prevent further leakage of fluid. The physician takes some blood from a vein in the mother's arm and injects a small amount into the opening in the spine. The blood clots in the space, which should prevent fluid from leaking at the site.
A patient who is 39 weeks' gestation is in labor has started pushing during delivery. The nurse is performing external fetal monitoring during this time and notes that the baby's heart rate drops during contractions but increases again by the time the contraction has ended. Which action of the nurse is most appropriate? -Continue to monitor the patient and the fetal heart rate -Prepare for immediate cesarean section -Provide oxygen by facemask and increase the rate of the IV -Apply pressure to the patients lower abdomen and contact the physician
Rationale: External fetal monitoring during labor allows the nurse and the prescribing provider to assess the fetal heart rate and determine how the baby is responding to contractions. When the fetal heart rate drops during the contraction but then increases again by the time it has ended, the patient has experienced an early deceleration. Typically, no intervention is required and the nurse should monitor the patient for changes.
You are doing fetal heart monitoring (FHM) on your patient who is 39-weeks along and been in labor for 14 hours. Which of the following findings is the LEAST concerning to you? -Fetal heart rate of 155-170 for 7 minutes -Non-reactive stress test -Variable deceleration lasting 90 seconds -Late delerations
Rationale: Fetal tachycardia for less than 10 minutes is something to watch, but not as concerning as the other options listed. Late decels, a non-reactive stress test, and variable decelerations longer than 1 minute are all concerning non-reassuring findings that must be reported to the MD.
A nurse is caring for a 28-year-old pregnant patient who is in labor with her first baby. The patients partner has been at the hospital briefly during the time that the patient has been in labor, but the nurse is unsure whether he will be present during delivery. Which question from the nurse would be most appropriate when discerning the role of the father in this situation? -Is there anyone you can call who will help you during this time? -Do you feel like your partner is there for you? -Will you want a coach or partner in the delivery room with you? -Are you sure that you want the baby's father here with you?
Rationale: In a situation where a patient is in labor and the nurse is not sure about the level of support for the patient, the nurse can ask questions that may help her to best discern who is available. In this case, the nurse may retrieve more information by gently asking the patient if there is someone she wants in the delivery room, rather than directly asking if it will be the patients partner, as this could cause tension between the patient and her partner.
You are doing fetal heart monitoring (FHM) on your patient who is 39-weeks along and been in labor for 14 hours. Which of the following findings is the MOST concerning to you? -Variable deceleration lasting 25 seconds -Variability noted -Late decelerations -Accelerations noted
Rationale: Late decel's are indicative of a placental issue. This is a non-reassuring, concerning finding. Variability, accelerations, and variable decels less than 1 minute are all not concerning.
A patient in labor is being admitted to the hospital for delivery of her baby. The patient has been seen for regular prenatal visits and has been monitored closely because of a diagnosis of placenta previa. The nurse notes that the physician on call starts to perform a pelvic exam to assess cervical dilation. Which response from the nurse is appropriate? -Gather a speculum to assist the physician -Ask the patient to bear down during the exam -Remind the physician of the patients condition -Set up supplies for imminent delivery
Rationale: Placenta previa is a condition in which the placenta is partially covering the vaginal opening. Most women in labor who develop placenta previa have a cesarean section to reduce the risk of harm to the baby. The physician or the nurse should not perform a cervical check to assess cervical dilation, as this could cause trauma to the placenta.
A nurse is caring for a patient who is in labor; the patient has an external fetal heart monitor in place and the nurse is watching the baby's heart rate. The nurse notes that the infants heart rate increases to 180 beats per minute and stays elevated for several minutes before returning to 140 bpm again. Which of the following nursing actions is most appropriate? -Turn down the fluid rate on the IV -Administer the next dose of oxytocin through the IV -Continue to monitor and do nothing -Administer oxygen to the mother
Rationale: The heart rate in the description suggests fetal tachycardia, an abnormal fetal heart rate that can be detected on the fetal monitor. Tachycardia could occur from such conditions as maternal fever or dehydration, or there could be a condition affecting the baby's heart. The nurse should turn up the IV rate and administer oxygen to the mother to improve hydration and oxygenation to the mother and the baby.
You are working in labor and delivery. Your patient has been in labor for 9 hours. She put on her call light and said that she needs to speak to her nurse immediately. You go into the room and complete an assessment. You immediately noted the baby's shoulder as the presenting part with the umbilical cord under it. You have called for assistance from your colleagues, one of whom is emergently notifying the MD. Which of the following interventions is NOT something you should do in this situation? -Reposition the patient into a knee-chest position -Reinsert the presenting part and cord -Elevate the presenting part -Wrap the cord loosely in a sterile towel, saturated with warm saline
Rationale: The situation described is that of a prolapsed umbilical cord and an emergency. The pressure from the presenting part on cord prevents the baby from being appropriately oxygenated. The provider must be immediately notified, as delivery will be imminent. Pressure must be removed from the cord, therefore elevating the presenting part is crutial. Mom should get in a knee-chest position as you elevate the shoulder to relieve this pressure. The cord should be wrapped in a sterile towel, ideally by an assisting colleague as you elevate the presenting part. You should NEVER try to reinsert the presenting part or cord