Labor and Delivery

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take??

Apply perineal pressure to the emerging fetal head

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse priority?

Blood pressure 80/56 mm Hg

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in a RSA position. Which of the following fetal presentation should the nurse document in the clients medical record?

Breech

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following should the nurse report to the provider?

Urinary output 40 ml in 2 hr

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late deceleration on the monitor strip and interprets them as indicating which of the following?

Utero placental insufficiency

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, a receiving IV fluid. The nurse observes variable deceleration in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding.

Variable decelerations are due to umbilical cord compress

A nurse is caring for a client who is preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?' Which of the following responses should the nurse offer?

You must be feeling scared and powerless

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with Pre-eclampsia?

Deep tendon reflexes of +1

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The clients respiratory rate is 10/min and deep tendon reflexes are absent. Which of the following actions should the nurse take?

Discontinue the medication infusion

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor for the client for which of the following adverse effects that should be reported to the provider?

Dyspnea

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the clients amniotic membranes are intact. The client suddenly states that sh needs to push. Which of the following actions should the nurse take?

Have the client pant during the next contraction

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart of 138/min and no uterine contractions. The clients vital sings are BP 98/52, Hr 118, T 36.4. Which of the following is the priority nursing action?

Initiate IV access

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Insert a gloved hand into the vagina to relieve pressure on the cord

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and ask the nurse about the purpose of this medication. The nurse should provide which of the following explanation?

It promotes fetal lung maturity

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contraction have a duration of 1 min and a frequency 3 min. The nurse obtains the following vital signs: fetal heart 130, maternal heart rate 128, and maternal blood pressure 92/54. Which of the following is the priority action for the nurse to take?

Position the client with one hip elevated

A nurse is caring for a client who is preterm labor with a current L/S ration of 1:1. Which of the following actions should the nurse take?

Administer betamethasone 12 mg IM

A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which of the following actions should the nurse take first?

Change the client position

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Check the cervix prior to analgesic administration

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Contractions lasting longer than 90 seconds

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply)

- Administer magnesium sulfate IV - Provide a dark, quiet environment - Ensure that calcium gluconate is readily available

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the followings findings confirm to the nurse that the client is in labor?

Cervical dilation