mother baby unit 3

assessing a neonate immediately after birth who was delivered using forceps, the nurse confirms facial paralysis. which information would the nurse provide to the mother? a.) "it should resolve within a few days" b.) "take the newborn to a neurologist immediately" c.) "the infant requires phototherapy for a few minutes" d.) "refrain from breast-feeding the infant for a few days"

a.) "it should resolve within a few days"

an amniotomy is performed on a client admitted for labor augmentation w/ oxytocin. immediately after the amniotomy the nurse assesses the fetal heart rate for at least a full minute for signs of which complication? a.) infection b.) uterine atony c.) umbilical cord prolapse d.) maternal hypertension

c.) umbilical cord prolapse

which clinical finding during labor induction requires the nurse to discontinue the oxytocin infusion? a.) contractions occurring every 3 minutes and lasting 60 seconds b.) elevation of blood pressure from 110/70 to 135/85 mm HG over 30 minutes c.) rupture of membranes w/ amniotic fluid that contains threads of blood and mucus d.) several late fetal heart rate decelerations that return to baseline after the contraction is over

d.) several late fetal heart rate decelerations that return to baseline after the contraction is over

which clinical finding during labor induction requires the nurse to discontinue the oxytocin infusion? a.) contractions occurring every 3 minutes and lasting 60 seconds b.) elevation of blood pressure from 110/70 to 135/85 mmHG over 30 minutes c.) rupture of membranes w/ amniotic fluid that contains threads of blood and mucus d.) several late fetal heart rate decelerations that return to baseline after the contraction is over

d.) several late fetal heart rate decelerations that return to baseline after the contraction is over

a client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. which statement would be the correct interpretation of these findings? a.) infection is present b.) cesarean birth is necessary c.) precipitate birth is imminent d.) the fetus may be compromised in utero

d.) the fetus may be compromised in utero

in which location will the fetal heart tones be heard if the fetus position is left occiput anterior (LOA)?

fetus's back is on the left side of the mother

which factor distinguishes true labor from false labor? a.) cervical dilation is evident b.) contractions stop when the client walks around c.) the client's contractions progress only when she is in a side-lying position d.) contractions occur immediately after the membranes rupture

a.) cervical dilation is evident

which action would the nurse take when a client's membranes rupture while her labor is being augmented w/ an oxytocin infusion and variable decelerations in the fetal heart rate occur? a.) change the client's position b.) take the client's blood pressure c.) stop the client's oxytocin infusion d.) prepare the client for an immediate birth

a.) change the client's position

which is the priority assessment when the membranes rupture? a.) fetal heart rate b.) cervical dilation and effacement c.) amount, color, and odor of amniotic fluid d.) frequency, intensity, and duration of contractions

a.) fetal heart rate

which characteristics are score on a biophysical profile? select all that apply. one, some, or all responses may be correct. a.) fetal tone b.) fetal position c.) fetal movement d.) amniotic fluid index e.) fetal breathing movements f.) contraction stress test results

a.) fetal tone c.) fetal movement d.) amniotic fluid index e.) fetal breathing movements

which information would be given to a client about her position while an internal fetal monitor is in place? a.) the most comfortable position may be assumed b.) monitoring is more accurate in the side-lying position c.) maintaining a supine position holds the internal electrodes in place d.) the monitor leads need to be detached when sitting on the bedpan

a.) the most comfortable position may be assumed

a multipara whose membranes have ruptured is admitted in early labor. assessment reveals a breech position, cervical dilation of 3 cm, and fetal station of -2. for which complication would the nurse assess when caring for this client? a.) vaginal bleeding b.) urinary tract infection c.) prolapse of the umbilical cord d.) meconium in the amniotic fluid

c.) prolapse of the umbilical cord

which instruction would the nurse include when teaching episiotomy care? a.) rest w/ legs elevated at least 2 times a day b.) avoid stair climbing for several days after discharge c.) perform perineal care after toileting until healing occurs d.) continue sitz baths 3 times a day if they provide comfort

c.) perform perineal care after toileting until healing occurs

a nonstress test (NST) is scheduled for a client w/ mild preeclampsia. during an NST, the client asks what it means when the fetal heart rate goes up every time the fetus moves. which is an appropriate response? a.) "these accelerations are a sign of fetal well-being" b.) "these accelerations indicate fetal head compression" c.) "umbilical cord compression is causing these accelerations" d.) "uteroplacental insufficiency is causing these accelerations"

a.) "these accelerations are a sign of fetal well-being"

on entering the room of a client in active labor the nurse notes the client is ashen grey, dyspneic, and clutching her chest. which is the nurse's immediate action after pressing the emergency light? a.) administer oxygen by face mask b.) check for rupture of the membranes c.) begin cardiopulmonary resuscitation (CPR) d.) increase the rate of intravenous (IV) fluids

a.) administer oxygen by face mask

which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beats over the baseline rate of 135 beats per minute that lasts 15 seconds? a.) an acceleration b.) an early increase c.) a sonographic motion d.) a tachycardic heart rate

a.) an acceleration

a client required an extensive episiotomy because her newborn was large. which nursing intervention will minimize edema and lessen discomfort associated w/ an episiotomy? a.) applying ice packs to the perineum b.) positioning the client off the incisional area c.) administering an oral analgesic to the client d.) spraying the perineum w/ a local anesthetic

a.) applying ice packs to the perineum

which is the nurse's immediate action when a laboring client experiences a spontaneous rupture of membranes? a.) assess the fetal heart rate b.) estimate the amount of fluid c.) assess the characteristics of the fluid d.) reposition the client to a side-lying position

a.) assess the fetal heart rate

which is the priority nursing action when a client at 40 weeks' gestation has an amniotomy performed to facilitate labor? a.) assessing the fetal heart rate b.) obtaining the maternal vital signs c.) documenting the time of the procedure d.) monitoring the frequency of contractions

a.) assessing the fetal heart rate

what is the appropriate intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration? a.) elevating the legs b.) repositioning the client from side to side c.) increasing the rate of intravenous infusion d.) administering oxygen by way of face mask

b.) repositioning the client from side to side

an amniotomy is performed in a laboring client at 42 weeks' gestation. place the nursing care actions in their order of priority

1.) checking the fetal heart rate tracings 2.) inspecting the perineum for umbilical cord prolapse 3.) assessing the characteristics of the amniotic fluid 4.) monitoring the client for signs of an infection

thirty minutes after initiation of epidural anesthesia the fetus is experiencing late decelerations. list the nursing actions in order of PRIORITY

1.) reposition the client on her side 2.) increase intravenous fluids 3.) reassess the fetal heart rate (FHR) pattern 4.) notify the healthcare provider if late decelerations persist 5.) document interventions and related maternal/fetal responses

which is the expected color and consistency of amniotic fluid at 36 weeks' gestation? a.) clear, dark amber colored, and containing shreds of mucus b.) straw colored, clear, and containing little white specks c.) milky, greenish yellow, and containing shreds of mucus d.) greenish yellow, cloudy, and containing little white specks

b.) straw colored, clear, and containing little white specks

a client in labor is admitted to the birthing unit 20 hrs after the membranes have ruptured. which is a possible complication for this client? a.) cord prolapse b.) placenta previa c.) maternal sepsis d.) abruptio placentae

c.) maternal sepsis

the electronic fetal monitor on a client receiving an infusion of oxytocin (Pitocin) displays contractions every 2 minutes and lasting 95 seconds. which is the appropriate nursing action? a.) stop the oxytocin (Pitocin) infusion b.) administer oxygen at 8 to 10 L/min c.) increase the main line fluid delivery rate to 150 mL/hr d.) prepare the client for insertion of an intrauterine pressure catheter

a.) stop the oxytocin (Pitocin) infusion

which action would the nurse implement to enhance safety for a laboring client and fetus w/ a prolapsed cord? select all that apply. one, some, or all responses may be correct. a.) increasing the client's intravenous fluid drip rate b.) placing the client in the extreme Trendelenburg position c.) administering oxygen to the client via a nonrebreather mask d.) immediately notifying the client's primary healthcare provider e.) quickly gloving the examining hand and inserting two fingers into the vagina to the cervix

a.) increasing the client's intravenous fluid drip rate b.) placing the client in the extreme Trendelenburg position c.) administering oxygen to the client via a nonrebreather mask d.) immediately notifying the client's primary healthcare provider e.) quickly gloving the examining hand and inserting two fingers into the vagina to the cervix

a client's membranes rupture 20 hrs before admission. she gave birth 18 hrs after admission. for which postpartum complication is this client at risk? a.) infection b.) hemorrhage c.) uterine atony d.) amniotic fluid embolism

a.) infection

which is the priority nursing action when caring for a client who has just had an amniotomy and the fetal heart rate immediately decreases from 140 to 80 beats/min? a.) inspecting the vagina b.) administering oxygen c.) increasing the intravenous fluids d.) placing the client in the knee-chest position

a.) inspecting the vagina

which fetal position would the nurse suspect when the fetal heartbeat is heard most distinctly in the upper left quadrant of the abdomen of the client in early labor? a.) left sacral anterior b.) left mentum anterior c.) left occiput anterior d.) left occiput transverse

a.) left sacral anterior

which would the nurse identify as the most widely used off-label medication for cervical ripening and the enhancement of uterine muscle tone? a.) misprostol b.) mifepristone c.) dinoprostone d.) methylergonovine

a.) misprostol

which statement indicates a client understands the meaning of having a reactive nonstress test? a.) normal because of increases in fetal heart rate (FHR) w/ fetal movement b.) abnormal because of a decrease in FHR between contractions c.) abnormal because of variability w/ each contraction d.) normal because the FHR remained unchanged w/ maternal movement

a.) normal because of increases in fetal heart rate (FHR) w/ fetal movement

between contractions that are 2 to 3 minutes apart and last about 45 seconds, the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. which is the priority nursing action? a.) notify the health care provider b.) resume continuous fetal heart monitoring c.) continue to monitor the maternal vital signs d.) document the fetal heart rate as an expected response to contractions

a.) notify the health care provider

which medications would the nurse identify as being used to induce labor in pregnant clients? select all that apply. one, some, or all responses may be correct. a.) oxytocin b.) ergonovine c.) carboprost d.) misoprostol e.) dinoprostone

a.) oxytocin d.) misoprostol e.) dinoprostone

which methods qualify as alternative therapies for pain. select all that apply. one, some, or all responses may be correct a.) prayer b.) hypnosis c.) medication d.) aromatherapy e.) guided imagery

a.) prayer b.) hypnosis d.) aromatherapy e.) guided imagery

which is the focus of nursing care for a laboring client when the umbilical cord suddenly prolapses and protrudes from the vagina? a.) preparing the client for surgery b.) replacing the cord in the vaginal vault c.) checking the fetal heart rate every 15 minutes d.) starting oxygen at 10 L per minute via a tight facemask

a.) preparing the client for surgery

which is the action of oxytocin? select all that apply. one, some, or all responses may be correct. a.) promotes milk ejection during lactation b.) controls uterine bleeding after delivery c.) induces labor when uterine contractions are weak d.) prevents uterine fibrosis in women of reproductive age e.) prevents high-risk intrauterine fetal positions before delivery

a.) promotes milk ejection during lactation b.) controls uterine bleeding after delivery c.) induces labor when uterine contractions are weak

by which mechanism do sitz baths aid healing of an episiotomy? a.) promoting vasodilation b.) cleansing perineal tissue c.) softening the incision site d.) tightening the rectal sphincter

a.) promoting vasodilation

late decelerations are present on the monitor strip of a client w/ an intravenous infusion who received epidural anesthesia 20 minutes ago. which action would the nurse take immediately? a.) reposition the client from supine to left lateral b.) increase the intravenous flow rate from 125 to 150 mL/hr c.) administer oxygen at a rate of 8 to 10 L/min by way of facemask d.) assess the maternal blood pressure for a systolic pressure below 100 mmHG

a.) reposition the client from supine to left lateral

oxytocin is prescribed for a client in labor after a period of ineffective contractions. which nursing interventions are most important if strong contractions that last 90 seconds or longer occur. select all that apply. one, some, or all responses may be correct. a.) stopping the infusion b.) turning the client on her side c.) notifying the primary healthcare provider d.) verifying the duration of contractions e.) administering magnesium sulfate

a.) stopping the infusion b.) turning the client on her side c.) notifying the primary healthcare provider d.) verifying the duration of contractions

which impending problem would the nurse suspect when caring for a client w/ bloody urine in the indwelling catheter collection bag, after an emergency cesarean birth? a.) surgical trauma to the bladder b.) urinary infection from the catheter c.) uterine relaxation w/ increased lochia d.) disseminated intravascular coagulopathy

a.) surgical trauma to the bladder

a client has delivered her infant by cesarean birth. the nurse monitors the newborn's respiration closely because infants born via the cesarean method are prone to atelectasis. why does this occur? a.) the ribcage is not compressed and released during birth b.) the sudden temperature change at birth causes aspiration c.) there is usually oxygen deprivation after a cesarean birth d.) there is no gravity during the birth to promote drainage from the lungs

a.) the ribcage is not compressed and released during birth

the health care provider prescribes a contraction stress test (CST) for a client at 33 weeks' gestation whose nonstress test (NST) was nonreactive and whose biophysical profile (BPP) was inconclusive. which maternal conditions would prompt the nurse to question the prescription? select all that apply. one, some, or all responses may be correct. a.) hypertension b.) preterm labor c.) placenta previa d.) cervical insufficiency e.) premature rupture of membranes

b.) preterm labor c.) placenta previa d.) cervical insufficiency e.) premature rupture of membranes

at 36 weeks' gestation a client is scheduled for a contraction stress test (CST) and the nurse explains the procedure. which statement indicated that the client understands the teaching? a.) "if this test causes my labor to begin early, I would need a cesarean section" b.) "if my baby's heart rate is okay, my labor probably won't be induced today" c.) "I hate having needles in my arm, but I understand why it's necessary" d.) "I hope the baby doesn't get restless after the test; it can get uncomfortable"

b.) "if my baby's heart rate is okay, my labor probably won't be induced today"

a client is experiencing a prolonged labor and is frustrated and very concerned about the situation. the nurse acknowledges the client's feelings and then makes which response? a.) "I'll leave so you can talk to your partner" b.) "may I rub your back? let me know if the pressure makes you feel better or worse" c.) "let's talk some more about what's really bothering you" d.) "women usually become weary and frustrated during labor"

b.) "may I rub your back? let me know if the pressure makes you feel better or worse"

a postpartum client receiving an intravenous infusion of oxytocin to stimulate labor asks the nurse why it is not being discontinued now that the baby is born. which response by the nurse is MOST appropriate? a.) "the oxytocin promotes the flow of lochia" b.) "the contractions prevent excessive bleeding" c.) "the oxytocin eases the discomfort of involution" d.) "the oxytocin enhances the healing of tissue in the uterus"

b.) "the contractions prevent excessive bleeding"

during a prenatal education class, the nurse discusses the importance of fetal movement awareness. why is this an important concept to teach? a.) an increase in fetal movement indicates the onset of labor is near b.) a decrease in fetal movement necessitates an evaluation of fetal well-being c.) fetal movement awareness increases the emotional bond of mother to fetus d.) a perceived decrease in fetal movement is a symptom of preeclampsia

b.) a decrease in fetal movement necessitates an evaluation of fetal well-being

which fetal heart pattern indicates cord compression? a.) smooth, flat baseline tracings of 135 beats/min b.) abrupt decreases in fetal heart rate that are unrelated to the contractions c.) accelerations in the fetal heart rate of 10 beats/min above baseline d.) decelerations when a contraction begins that return to baseline when the contraction ends

b.) abrupt decreases in fetal heart rate that are unrelated to the contractions

a client in her 36th week of gestation is admitted w/ vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. for which intervention would the nurse prepare? a.) a high-forceps birth b.) an immediate cesarean birth c.) insertion of an internal fetal monitor d.) administration of an oxytocin infusion

b.) an immediate cesarean birth

when the fetal head begins to crown during an emergency precipitous birth, how would the nurse respond? a.) pressing firmly on the fundus b.) applying gentle perineal pressure c.) encouraging the client to push forcefully d.) telling the client to take prolonged deep breaths

b.) applying gentle perineal pressure

the nurse applies fetal and uterine monitors to the abdomen of a client in active labor. when the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below baseline lasting 15 seconds. which is the next nursing action? a.) calling the primary healthcare provider b.) changing the maternal position c.) obtaining the maternal blood pressure d.) preparing the environment for an immediate birth

b.) changing the maternal position

an electronic fetal monitor is applied to a client in labor who is dilated to 4cm. which assessment finding would cause the nurse to notify the healthcare provider? a.) contractions every 4 minutes that last 50 seconds b.) contractions every 1 to 2 minutes lasting 90 seconds c.) fetal heart rate accelerations at the beginning of a contraction d.) fetal heart rate decelerations to 110 beats/min before the peak of a contraction

b.) contractions every 1 to 2 minutes lasting 90 seconds

which action would the nurse take FIRST when a client receiving oxytocin to augment labor begins to moan loudly, and her contractions become more intense and prolonged, w/ little or no rest period between them? a.) continue the fetal monitoring b.) discontinue the oxytocin infusion c.) notify the primary healthcare provider d.) place the client in the knee-chest position

b.) discontinue the oxytocin infusion

which action identified by the student indicates to the nurse an understanding of oxytocin in a pregnant client at term? a.) ejection of milk b.) induction of labor c.) induction of abortion d.) control of uterine bleeding

b.) induction of labor

which statement contains information that would be included when answering a client's questions about episiotomy versus laceration? a.) lacerations are more painful than an episiotomy b.) lacerations are easier to repair than an episiotomy c.) an episiotomy causes less posterior trauma than lacerations d.) an episiotomy is preferred over lacerations, according to evidence-based practice

b.) lacerations are easier to repair than an episiotomy

a client who is having her labor induced w/ oxytocin has internal fetal monitoring in place. her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mmHg on an intrauterine pressure catheter. the baseline fetal heart rate is 130 to 140 beats/min w/ variability of about 15 beats/min. the nurse notices that with the past 2 contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. which type of pattern is this? a.) bradycardia b.) late decelerations c.) early decelerations d.) variable decelerations

b.) late decelerations

a client w/ a large fetus is to have a pudendal block during the second stage of labor. which would the nurse plan to instruct the client regarding the effectiveness of the block? select all that apply. one, some, or all responses may be correct. a.) contractions will decrease b.) perineal pain will not be felt c.) bladder sensation may be lost d.) an episiotomy may not be needed e.) the bearing-down reflex will be diminished

b.) perineal pain will not be felt e.) the bearing-down reflex will be diminished

immediately following rupture of membranes, the fetal heart rate monitor shows variable decelerations of more than 90 seconds followed by bradycardia. which condition does the nurse suspect? a.) fetal acidosis b.) prolapsed cord c.) head compression d.) uteroplacental insufficiency

b.) prolapsed cord

a contraction stress test (CST) performed on a client at 40 weeks' gestation is interpreted as negative. which conclusion would the nurse draw from this interpretation? a.) testing will be repeated in 24 hrs because the results indicate hyperstimulation b.) there will be weekly retesting because at this time the fetus has adequate oxygen reserves c.) emergency birth will be considered because the fetal heart rate has early decelerations w/ uterine contractions d.) induction of labor will be performed because fetal heart rate accelerations w/ movement are indicative of a false result

b.) there will be weekly retesting because at this time the fetus has adequate oxygen reserves

an intravenous infusion of oxytocin is started to induce labor in a client. when the client's contractions begin, they are 1.5 to 2 minutes in duration. while the nurse is in the room, one contraction lasts 3 minutes. which action would the nurse take FIRST? a.) give oxygen by nasal cannula b.) turn off the oxytocin infusion c.) reposition the monitoring belts d.) place a call light next to the client

b.) turn off the oxytocin infusion

which complication would the nurse be alert for in a client receiving an oxytocin infusion to induce labor? a.) intense pain b.) uterine tetany c.) hypoglycemia d.) uterine cord prolapse

b.) uterine tetany

late fetal heart rate decelerations begin to appear when a client's cervix is dilated 6 cm, and her contractions are occurring every 4 minutes and lasting 45 seconds. which is the likely cause of these late decelerations? a.) imminent vaginal birth b.) uteroplacental insufficiency c.) pattern of nonprogressive labor d.) normal pressure on the presenting part during contractions

b.) uteroplacental insufficiency

the doctor has written an order for a contraction stress test (CST). the presence of which condition would prompt the nurse to question the order? a.) proteinuria b.) vaginal bleeding c.) sickle cell disease d.) gestational hypertension

b.) vaginal bleeding

after the vaginal birth of an infant weighing 8 lb, 13 oz (3997 g) an ice pack is applied to a client's perineum to ease the swelling and pain. subsequently the client complains, "my vagina feels so full and heavy and the pain in it and in my rectum is excruciating." which problem would the nurse suspect is the cause of the pain? a.) full bladder b.) vaginal hematoma c.) infected episiotomy d.) enlarged hemorrhoids

b.) vaginal hematoma

a client in labor is having an indwelling urinary catheter inserted. which action by the nurse would help prevent late decelerations of the fetal heart rate during this procedure? a.) position both the client's legs in stirrups simultaneously b.) urge the client to take deep breaths frequently c.) place a rolled towel under the client's right hip d.) loosen the transducer belts around the client's abdomen

c.) place a rolled towel under the client's right hip

which information would the nurse provide to the client who is being prepared for a contraction stress test (CST)? a.) "the test will be discontinued after at least 6 contractions are observed" b.) "you'll need to provide a urine specimen before the test" c.) "the fetal heart rate will be monitored for about 20 minutes before the test begins" d.) "you'll be placed in a right lateral position that must be maintained throughout the test"

c.) "the fetal heart rate will be monitored for about 20 minutes before the test begins"

which condition contraindicates oxytocin induction? a.) chorioamnionitis b.) post-term pregnancy c.) active gentical herpes infection d.) hypertension associated w/ pregnancy

c.) active gentical herpes infection

a client in labor is experiencing discomfort because her fetus is in the occiput posterior position. which nursing action will help relieve this discomfort? a.) positioning her on the left side b.) using effleurage on her abdomen c.) applying pressure against her sacrum d.) placing her in the semi-Fowler position

c.) applying pressure against her sacrum

in which location would the doppler ultrasound transducer be placed to best auscultate fetal heart tones when the fetus is in the right occiput posterior (ROP) position? a.) above the umbilicus in the midline b.) above the umbilicus on the left side c.) below the umbilicus on the right side d.) below the umbilicus near the left groin

c.) below the umbilicus on the right side

an infant is admitted to the nursery after a shoulder dystocia vaginal delivery. for which condition would the nurse assess the newborn? a.) facial paralysis b.) cephalohematoma c.) brachial plexus injury d.) spinal cord syndrome

c.) brachial plexus injury

when a fetus is in a footling breech presentation, the nurse plans and implements care w/ which consideration in mind? a.) severe back discomfort will occur b.) length of labor usually is shortened c.) cesarean birth probably will be necessary d.) meconium in the amniotic fluid is a sign of fetal hypoxia

c.) cesarean birth probably will be necessary

a client who is in labor is admitted 30 hours after her membranes ruptured. which condition is this client at increased risk for? a.) cord prolapse b.) placenta previa c.) chorioamnionitis d.) abruptio placentae

c.) chorioamnionitis

which is a potential cause of fetal tachycardia when a client is in active labor? a.) fetal head compression b.) umbilical cord compression c.) increased maternal metabolism d.) pudendal anesthesia administration

c.) increased maternal metabolism

an oxytocin infusion is prescribed to augment labor for a client w/ mild contractions that last 30 seconds and are 3 to 5 minutes apart. which is the priority nursing intervention at this time/ a.) checking cervical dilation every hour b.) keeping the labor environment dark and quiet c.) infusing oxytocin by piggybacking into the primary line d.) positioning the client on the left side throughout the infusion

c.) infusing oxytocin by piggybacking into the primary line

a client who is 38 weeks' pregnant has a nonstress test (NST). the resulting fetal monitor strip is shown. which interpretation would the nurse assign to this finding? a.) negative because of a lack of contractions b.) nonreassuring; fetal heart rate lacks variability c.) reassuring; fetal heart rate accelerates w/ movement d.) positive; demonstrates decelerations w/ fetal movements

c.) reassuring; fetal heart rate accelerates w/ movement

which action would the nurse take when a 15-beat-per-minute acceleration of the fetal heart rate above the baseline occurs during a contraction? a.) call the practitioner to prepare for an imminent birth b.) turn the mother on her left side to increase venous return c.) record the fetal response to contractions and continue to monitor the heart rate d.) document the fetal heart rate abnormality and monitor the fetal heart rate continuously

c.) record the fetal response to contractions and continue to monitor the heart rate

when the fetal monitor is applied to a client's abdomen, it records late decelerations. which action would the nurse take? a.) notify the healthcare provider b.) elevate the head of the bed c.) reposition the client on her left side d.) administer oxygen by way of facemask

c.) reposition the client on her left side

which of these presentations would indicate that the nurse should direct a primipara to call a healthcare provider? a.) bloody show or back pressure occurring w/ no contractions b.) irregular contractions coming 10 minutes apart c.) rupture of membranes or contractions 5 minutes apart d.) contractions 12 minutes apart and lasting about 30 seconds

c.) rupture of membranes or contractions 5 minutes apart

which inference would the nurse make upon noting a newborn is unable to close their eyes completely, has drooping to the corner of the mouth, and absent wrinkling of the forehead and nasolabial fold? a.) the neonate has bleeding in the subgaleal layer from labor b.) the neonate's cranial nerve V was pressurized during labor c.) the neonate's cranial nerve VII was pressurized during labor d.) the neonate was exposed to gonorrheal infection during labor

c.) the neonate's cranial nerve VII was pressurized during labor

an amniotomy is performed on a client admitted for labor augmentation with oxytocin. immediately after the amniotomy the nurse assesses the fetal heart rate for at least 1 full minute for signs of which complication? a.) infection b.) uterine atony c.) umbilical cord prolapse d.) maternal hypertension

c.) umbilical cord prolapse

which condition is most commonly associated w/ late decelerations of the fetal heart rate? a.) head compression b.) maternal hypothyroidism c.) uteroplacental insufficiency d.) umbilical cord compression

c.) uteroplacental insufficiency

a nurse is caring for a client in the first stage of labor, and an external fetal monitor is in place. which do the tracings indicate? a.) fetal tachycardia b.) early accelerations c.) variable decelerations d.) inadequate long-term variability

c.) variable decelerations

for which adverse reaction caused by a prolonged oxytocin infusion to augment labor would the nurse monitor the client? a.) change in affect b.) hyperventilation c.) water intoxication d.) fever

c.) water intoxication

while caring for a client who has has a positive contraction stress test (CST), which complication would the nurse suspect? a.) preeclampsia b.) placenta previa c.) imminent preterm birth d.) uteroplacental insufficiency

d.) uteroplacental insufficiency

which preexisting condition is an indication for a cesarean birth? a.) gonorrhea b.) chlamydia c.) chronic hepatitis d.) active genital herpes

d.) active genital herpes

which action would the nurse take first for a client who is in active labor and experiences sudden vaginal bleeding and increased uterine tone w/o relaxation between contractions? a.) transport the client for a cesarean birth b.) check the perineum for rupture of membranes c.) change the underpad and position the client on her left side d.) assess the fetal heart rate, uterine activity, and blood pressure

d.) assess the fetal heart rate, uterine activity, and blood pressure

when checking the cervical dilation of a client in labor, the nurse notes that the umbilical cord has prolapsed. which action would the nurse take in response to this finding? a.) check the fetal heart rate b.) turn the client on her side c.) attempt to reposition the umbilical cord into the uterus d.) assist the client into the Trendelenburg position

d.) assist the client into the Trendelenburg position

which common indication for a cesarean birth would the nurse discuss in a class for expectant parents? a.) placenta previa b.) primary uterine inertia c.) cervical insufficiency d.) cephalopelvic disproportion

d.) cephalopelvic disproportion

as a client enters the second stage of labor, fetal monitoring shows early decelerations of the fetal heart rate w/ a return to the baseline at the end of each contraction. which is the common cause of this fetal heart rate pattern? a.) maternal diabetes b.) fetal cord prolapse c.) maternal hypotension d.) fetal head compression

d.) fetal head compression

which descriptor would the nurse use when explaining to a client how to time the frequency of contractions? a.) from the ned of 1 contraction to the end of the next contraction b.) from the end of 1 contraction to the beginning of the next contraction c.) from the beginning of 1 contraction to the end of the next contraction d.) from the beginning of 1 contraction to the beginning of the next contraction

d.) from the beginning of 1 contraction to the beginning of the next contraction

which findings support the conclusion that a pregnant client's membranes have ruptured? select all that apply. one, some, or all responses may be correct. a.) the expelled fluid totals 500 mL b.) the expelled fluid is light yellow c.) the expelled fluid smells similar to urine d.) nitrazine paper turns blue on contact with fluid e.) microscopic examination of the fluid reveals ferning

d.) nitrazine paper turns blue on contact with fluid e.) microscopic examination of the fluid reveals ferning

which fetal heart tracing during labor can most likely result in fetal hypoxia and metabolic acidosis? a.) accelerations b.) variable decelerations c.) fetal heart rate variability d.) recurrent late decelerations

d.) recurrent late decelerations

which fetal heart rate pattern suggests compromised fetal oxygenation? a.) early decelerations w/ moderate variability b.) changes in baseline variability from 5 to 10 beats/min c.) increases in fetal heart rate from 135 to 150 beats/min w/ fetal activity d.) recurrent variable decelerations that last 60 seconds w/ minimal baseline variability

d.) recurrent variable decelerations that last 60 seconds w/ minimal baseline variability

which fetal heart rate pattern in labor would require immediate action from the nurse? a.) baseline of 140 beats per minute during contractions b.) uniformly drops to 120 beats per minute mirroring each contraction c.) fluctuates from 130 to 140 beats per minute unrelated to contractions d.) repeatedly drops abruptly to 90 beats per minute unrelated to contractions

d.) repeatedly drops abruptly to 90 beats per minute unrelated to contractions

which finding indicates a positive result when performing contraction stress test (CST)? a.) there is moderate variability b.) there are fetal heart rate accelerations w/ contractions c.) the fetal heart rate baseline is 155 beats per minute d.) there are recurrent late decelerations

d.) there are recurrent late decelerations

a newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. how would the nurse remove the electrode? a.) giving the electrode a quick jerk b.) turning the electrode clockwise until it is free c.) untwisting the wires before pulling the electrode out d.) twisting the electrode counterclockwise until it is free

d.) twisting the electrode counterclockwise until it is free

which result after 20 minutes of a nonstress test is suggestive of fetal activity? a.) absence of long-term variability b.) above-average fetal baseline heart rate of 160 beats/min c.) no late decelerations associated w/ contractions d.) two accelerations of 15 beats/min lasting 15 seconds

d.) two accelerations of 15 beats/min lasting 15 seconds

at which location can the fetal heart be heard when the fetus is in the left occiput posterior (LOP) positon?

left lower quadrant of the mother

physical assessment of a client in active labor reveals that the cervix is dilated 3 to 4 cm and 50% effaced, the fetus presentation is cephalic and is in the right sacrum anterior (RSA) position, and contractions are 5 minutes apart. where would the nurse place the stethoscope to best located the fetal heart tones?

right upper quadrant