MAT INTRA-P

A client with an obstetrical history of G3 P2002 was examined 5 minutes ago. Her cervix was 8 cm dilated and 100% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first?

Evaluate the progress of labor.

During delivery, the nurse notes that the baby's head has just been delivered. The nurse notes that the baby has just completed which of the following cardinal moves of labor?

Extension.

It is 1600. A laboring client with an obstetrical history of G1 P0000 who is 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies:

"A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear?

"I can't stand this pain any longer!"

A pregnant client at term called the labor suite at 1900, questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated:

"I took a shower about a half hour ago. The contractions hurt more than they did before."

One hour ago, a multiparous client was examined with the following results: 8 cm, 90% effaced, and + 1 station. She does not have an epidural and is now pushing involuntarily with contractions. The fetal head is seen at the vaginal introitus. The nurse concludes that the client is now:

10 cm dilated, 100% effaced, and + 5 station.

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time?

2 cm.

Which of the following actions would the nurse expect to perform before a woman is to have regional anesthesia? Select all that apply.

Assess fetal heart rate. Infuse 500-1,000 mL of Ringer's lactate solution. Monitor blood pressure every 5 minutes for 15 minutes. Have the woman empty her bladder.

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time?

Assess the fetal heart rate at least every 5 minutes during and after the contraction.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must the nurse perform at this time?

Carefully analyze the baseline data on the monitor tracing.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status?

Cervical examination.

A woman with an obstetrical history of G2 P0101, is 5 cm dilated and 75% effaced. She is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first?

Encourage the woman to perform the next level breathing.

Which of the following nonpharmacological interventions recommended by nurse-midwives may help a client at full term to go into labor? Select all that apply.

Engage in sexual intercourse. Ingest evening primrose oil.

A nurse is caring for a laboring woman who is in transition. She does not have an epidural for pain control. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply.

Increased bloody show. Uncontrollable urge to push. Inability to breathe through contractions.

The nurse auscultates a fetal heart rate of 150 beats per minute (bpm) on a client in early labor. Which of the following actions by the nurse is appropriate?

Inform the mother that the rate is normal.

In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider orders self-administered inhaled nitrous oxide (N2O) in a N2O 50% / O2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? Select all that apply.

Nausea. Light-headedness.

Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting, too." The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest and discuss which of the following labor pain-relieving methods with the client before requesting an order?

Nitrous oxide.

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions?

Occiput posterior.

A nurse has just performed Leopold's maneuvers on a client in labor. The nurse palpates the baby's buttocks as the presenting part and determines they are facing the mother's right side. Where should the nurse place the external fetal heartrate transducer?

Right upper quadrant (RUQ).

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following?

Scapula.

A nurse is teaching a class of expectant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques is the nurse teaching?

Slow chest breathing.

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do?

Take a cleansing breath before bearing down.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother?

The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head.

A woman who is in active labor is told by her obstetrician, "Your baby's head is flexed." When she asks the nurse what that means, what should the nurse say?

The baby's chin is resting on its chest.

While evaluating the fetal heart rate (FHR) monitor tracing on a client in labor, the nurse notes that there are decelerations present. Which of the following assessments must the nurse make at this time?

The relationship between the decelerations and the labor contractions.

A woman had a baby by spontaneous vaginal delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude?

The woman is about to deliver the placenta.

A woman with an obstetrical history of G1 P0000 at 40 weeks' gestation enters the labor suite stating that she is in labor. Upon examination the nurse finds that the woman is 2 cm dilated, 25% effaced, contracting every 12 minutes × 30 seconds. Fetal heart rate is 140 bpm with moderate variability and accelerations. What should the nurse conclude when reporting the findings to the primary healthcare practitioner?

The woman is in latent labor and could be sent home.

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion?

The woman talks and laughs during contractions.

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and -2 station. Which of the following has the nurse palpated?

Thin cervix.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women?

Utilizing visual aids like movies and posters during the classes.

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse gather from the woman's prenatal record when planning nursing care? Select all that apply.

Weight gain. Ethnicity and religion. Age. Gravidity and parity.

At which time/s during the latent phase of labor should the nurse assess the fetal heart rate pattern of a low-risk woman with an obstetrical history of G1 P0000? Select all that apply.

With vaginal examinations. Before administration of analgesics. Periodically throughout several contractions. Before ambulating.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective?

Provide direct sacral pressure.

The nurse sees the fetal head at the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following?

"The baby's head is almost crowning."

A client with an obstetrical history of G2 P1001, is 5 cm dilated and 90% effaced. She has just received an epidural. Which of the following actions is important for the nurse to take at this time?

Place a wedge under the woman's side.

The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time?

Provide caring labor support.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows moderate variability with a baseline of 140 bpm. What should the nurse do?

Provide caring labor support.

The Lamaze childbirth educator is teaching a class of expectant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques is the nurse teaching the women to do?

Push down with an open glottis.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate?

Ischial spines.

The nurse knows that which of the following responses is the primary rationale for the information taught in childbirth education classes?

Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle.

During a vaginal examination, the nurse palpates fetal buttocks that are in the left posterior position and are 1 cm above the ischial spines. Which of the following is consistent with this assessment?

LSP, -1 station.

When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior (LOA) position. Which is the best position for the nurse to place a fetoscope to hear the fetal heart rate?

Left lower quadrant.

The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the client's left and small objects are noted on the right of the uterus (the client's right). A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings?

Left occipital anterior (LOA).

Perform yoga exercises. Eat raw spinach.

Massage the breast and nipples.

A nurse is preparing to assist an anesthesia provider who is setting up for insertion of an epidural catheter. Which of the following positions should the nurse anticipate the provider might request the client to assume? Select all that apply.

Fetal position. Sitting position.

The childbirth education nurse is evaluating the learning of four women at term, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply.

The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." The client who says, "When I feel a gush of clear fluid from my vagina." The client who says, "If I ever notice a greenish discharge from my vagina."

An ultrasound report states, "The fetal head has entered the pelvic inlet." How should the nurse interpret this statement?

The fetal head has entered the true pelvis.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time?

Cover the woman's perineum with a sheet.

A multipara with a fetus in the LOA position at +3 station has had no pain medication during her labor. She is now in second stage. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate?

"The baby is going to be born very soon. It is really too late for an epidural."

A woman at 38 weeks' gestation calls her obstetrical provider's advice nurse and reports, "I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first?

-"You sound frightened."

Immediately following administration of epidural anesthesia, the nurse must monitor the mother for which of the following side effects?

Drop in blood pressure.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor, but feels no urge to push. The fetus is at zero station and the baseline fetal heart rate is 130 bpm with no decelerations. Which of the following nursing actions is appropriate at this time?

Coach the woman to hold her breath while pushing 3 to 4 times with each contraction.

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time?

Continue to provide encouragement during each contraction.

A nurse describes a client's contraction pattern as: frequency every 3 minutes and duration of 60 seconds. Which of the following responses corresponds to this description?

Contractions lasting 1 minute followed by a 120-second rest period.

An obstetrician is performing an amniotomy on a laboring woman in transition. Which of the following assessments must the nurse make throughout the procedure?

Fetal heart rate.

A woman has just arrived at the labor and delivery suite. Before reporting the client's arrival to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply.

Fetal heart rate. Contraction pattern. Vital signs.

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply.

Give the woman a back rub. Assist the woman with her breathing.

The nurse-midwife is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see?

Fetal heart rate acceleration.

A woman is in active labor and is being monitored electronically. She has just received fentanyl citrate 50 mcg IV for pain. Which of the following fetal heart rate responses would the nurse expect to see on the internal monitor tracing?

Decreased variability.

On examination of a full-term primiparous client, a labor nurse notes: active labor, right occiput anterior (ROA) position, 10 cm dilated, and + 3 station (using a 5-cm scale). Which of the following should the nurse report to the physician?

Descent is progressing well.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time?

Have the woman breathe into a bag.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief?

Her cervix has dilated from 2 to 4 cm.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see?

Hypertension.

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply.

Lengthening of the umbilical cord. Uterus rising in the abdomen and feeling globular.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse consider during the next contraction?

Monitor for signs of rectal pressure.

While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse?

The fetal lie is vertical.

In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions?

Performing effleurage.

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery?

Massages the perineum with mineral oil.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply.

Muscle relaxation. Pelvic rocking. Abdominal massage.