NCLEX Maternal - Intrapartum

The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?

With the hips elevated

The nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at minus one station. What should the nurse determine is the fetal presenting position/station?

1 cm above the ischial spine

The nurse is caring for a hospitalized client with a diagnosis of abruptio placentae. The nurse develops a nursing care plan and incorporates interventions to be implemented in the event of the development of shock. What is the initial nursing action that should be included in the plan if shock develops?

Turn the mother onto her side

A client in active labor calls the nurse to her bedside to report that when she went to the toilet to urinate, she passed a big gush of clear fluid and thinks that her water broke. The nurse immediately performs a sterile vaginal examination and discovers a pulsating, ropelike object in the vaginal canal. Which is the priority nursing consideration in this situation?

Umbilical cord compression

The labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action should the nurse implement to assist in preventing a sickle cell crisis from occurring during labor?

Administer the prescribed oxygen throughout labor

The nurse is planning care for a client in active labor. Which interventions should the nurse plan to implement if the client's amniotic fluid ruptures spontaneously? Select all that apply.

1. Assess fetal heart rate and pattern. 2. Assess the color, consistency, and odor of the fluid. 3. Measure the client's temperature every 2 hours. 4. Document the date and time of the spontaneous rupture of the membranes.

The nurse caring for a client in labor should plan to assess the fetal heart rate (FHR) at which specific times? Select all that apply.

1. Before ambulation 2. After vaginal examination 3. After rupture of the membranes 4. Before the administration of Oxytocin (Pitocin)

A client is admitted to the labor and delivery unit for a vaginal birth after cesarean (VBAC). The client, in early labor, expresses fear over the upcoming labor pain and her ability to handle the contractions. Which therapeutic statements should the nurse make to the client? Select all that apply.

1. Can you tell me more about your previous delivery? 2. You have fear about the pain of the contractions and the intensity of labor? 3. Are you concerned about having another c-section if your vaginal birth is unsuccessful?

The nurse is teaching the laboring client about the cardinal movements that a fetus in the vertex position makes through the pelvis during the labor process. Arrange those movements in order, beginning with the movement that occurs after engagement and ending with the movement that occurs at birth. All options must be used.

1. Decent 2. Flexion 3. Internal rotation 4. Extension 5. External rotation

A client is admitted to the labor and delivery unit for a labor induction. The health care provider has prescribed oxytocin (Pitocin) to be initiated by piggyback at an initial rate of 2 milliunits/min and increased by a rate of 2 milliunits/min every 30 minutes until contractions are 2 to 3 minutes apart, lasting 80 to 90 seconds. How many mL/hr will the nurse initially set the infusion pump if the dilution of the oxytocin is 10 units of oxytocin in 1000 mL of 0.225% normal saline? Fill in the blank.

12 ml/hr

A client in labor is at 40 weeks' gestation. The nurse checks the fetal heart rate (FHR) for a baseline rate and tells the client that the baby's heart rate is within normal limits. Which FHR finding does the nurse then document?

140 beats per minute

The nurse is monitoring a pregnant woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse take as a result of this observation?

Document the finding.

The nurse is caring for a pregnant woman who has had ruptured membranes for longer than 24 hours. The client is receiving intravenous antibiotics and asks the nurse why the antibiotics are being given. The nurse understands the physiological risk associated with prolonged rupture of membranes (ROM) when the nurse tells the client that the use of antibiotics is to prevent which condition?

Early onset neonatal B Streptococcus (GBS) disease

During clinical conference, a nursing instructor asks a nursing student to explain the purpose of effleurage for a client in early labor. Which statement by the student indicates an understanding of why this procedure is performed?

Effleurage is light stroking of the abdomen to facilitate relaxation during labor.

The nurse is caring for a client in active labor. Which priority action should the nurse perform to prevent fetal heart rate decelerations?

Encourage upright or side-lying maternal positions.

The nurse is caring for a client with a diagnosis of complete placenta previa who is having contractions. In preparing the client for delivery, which procedure should the nurse perform?

Insert a foley catheter

The nurse is performing a fetal assessment on a client in labor. The nurse determines that which finding indicates impaired fetal oxygenation?

Late decelerations

The nurse is evaluating the effectiveness of meperidine (Demerol) for pain management for a client in labor. The nurse determines that the medication was effective if the client exhibited which signs/symptoms?

Moderate pain relief while a progressive labor pattern continues

A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes. The client has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is decreasing, and a persistent nonreassuring fetal heart rate pattern is present. What intervention should the nurse immediately plan for?

Prepare the client for a cesarean delivery

A delivery room nurse is preparing a client for a cesarean delivery. Which position will promote maximum uteroplacental perfusion during this surgery?

Supine position with a wedge under the right hip.

The delivery room nurse is preparing a client for a cesarean delivery. The client is moved to the delivery room table and the nurse should place the client in which position?

Supine position with a wedge under the right hip.

The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?

Support in maintaining a sense of control.

The nurse has been encouraging the intake of oral fluids for a client in labor to improve hydration. Which indicates a successful outcome of this action?

A urine specific gravity of 1.020

A client in the transition phase of labor is being supported by her labor coach. The client is complaining about how the coach is applying sacral pressure. Which actions should the nurse implement? Select all that apply.

1. Explain to the coach that this is expected behavior from the mother during the transition phase. 2. Suggest the technique of counter pressure on the back with the use of a tennis ball to the coach 3. Reinforce that at this stage of labor the back discomfort is from the fetus moving further down in the pelvis.

The nurse has completed teaching a client who is in the early stage of labor what to expect when the labor progresses to the active stage. The nurse knows there is a need for further teaching if the client makes which statements? Select all that apply.

1. I will be able to start pushing at this phase of labor. 2. My contractions should be lasting only 30 seconds.

The nurse is monitoring a laboring client who is receiving a fentanyl epidural block. The nurse monitors for which side/adverse effects of a fentanyl epidural? Select all that apply.

1. Pruritis 2. Hypotension 3. Urinary Retention

A client in labor has a concurrent diagnosis of sickle cell anemia. Which action has priority to assist in preventing a sickling crisis from occurring during labor?

Administering oxygen

The nurse is caring for a client experiencing hypotonic labor contractions. The client is very discouraged with the progress she is making but adamantly refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client's behavior may be attributed to which?

A concern about her own and the baby's well being

The nurse should interpret the fetal heart tracing showing absent variability as indicative of which condition? Refer to figure.

A possible problem with the fetus that must be reported to the health care provider.

The labor room nurse is assisting with a delivery and monitoring the client for placental separation following the delivery of a viable newborn. The nurse should monitor for which sign that indicates the placenta has separated?

Change in the uterine contour

The nurse is caring for the client who has just had a precipitate delivery. Before attempting to deliver the placenta, which sign should the nurse wait for as an indication of placental separation?

Change in uterine shape

The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. What is the appropriate nursing intervention?

Continue to assess both vital signs and fetal heart rate as before the nerve block.

The maternity nurse is caring for a client in labor and performs an assessment on the client. The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats/min and regular. Which nursing action has the highest priority based on the assessment data?

Continue to monitor the client

The nurse is performing an assessment on a pregnant woman to determine whether labor has begun. Which finding is a sign of true labor?

Contractions begin in the lower abdomen and back and then radiate over the entire abdomen.

The nurse is caring for a client in active labor. Which natural and soothing techniques should the nurse plan to use during active labor to assist the client to effectively manage the labor process?

Counterpressure and effleurage.

The nurse is caring for a client who is having a precipitate delivery. For which abnormal assessment finding should the nurse monitor the client?

Decreased periods of uterine relaxation between contractions

The nurse receives a report at the beginning of the shift regarding a client with intrauterine fetal demise. On assessment of the client, which finding does the nurse expect to note?

Regression of pregnancy symptoms and absence of fetal heart tones.

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F, ate 2 hours ago, and indicates she has had no preparation for the cesarean delivery. Which action should the nurse plan to take first?

Report the time of the last food intake to the health care provider.

The nurse notes that a client in labor is changing body positions, bearing down, and making expiratory vocalizations. From this information, the nurse knows that the client is likely in what stage of labor?

Second stage, descent phase.

The nurse is caring for a client with gestational hypertension who is in labor. The nurse monitors the client closely for which complication of gestational hypertension?

Seizures

The nurse is monitoring a fetal heart rate (FHR). The nurse documents that a reassuring FHR pattern is present if which sign is noted?

Short term variability averaging 6 to 10 beats per minute and long term variability averaging 2 to 6 cycles per minute.

A client with gestational hypertension is in active labor. Which assessment finding should the nurse most likely expect to note?

Increased blood pressure

After the delivery of a newborn infant, the nurse prepares to assist in the delivery of the placenta. What is the best method to deliver the placenta?

Wait for placental separation, and then pull gently on the cord as the mother bears down

A client who is in labor has human immunodeficiency virus (HIV) and says to the nurse, "I know I will have a sick-looking baby." Which appropriate response should the nurse make?

You have concerns about how HIV will affect your baby?

The nurse is caring for a client at 30 weeks' gestation who is in preterm labor, and the health care provider prescribes betamethasone intramuscularly. The client asks the nurse why she is receiving corticosteroids. The nurse should tell the client that the betamethasone will do which action?

Help the baby's lungs mature faster

A client has just had a cesarean section to deliver a nonviable fetus because of abruptio placentae. The client has just been told that disseminated intravascular coagulopathy (DIC) is developing as a complication. She begins to cry and screams, "God, just let me die now!" Which response should the nurse expect to see in this client?

Hopelessness

The labor room nurse is caring for a client with a known history of sickle cell anemia who is in labor. The nurse takes which priority action to assist in preventing a sickle cell crisis from occurring during labor?

Administers the prescribed-as-needed oxygen throughout labor

A client asks the nurse how she can tell if labor is "real"? Which should the nurse give as an explanation? Select all that apply.

1. In true labor, the cervix begins to dilate. 2. In true labor, contractions often resemble menstrual cramps during labor. 3. In true labor, contractions tend to increase in frequency, duration and intensity.

The nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes the fetal heart rate pattern is showing severe late decelerations. How should the nurse prioritize nursing actions? Arrange the actions in the order that they should be performed. All options must be used.

1. Stop the oxytocin infusion 2. Reposition the client to her left side 3. Administer oxygen by face mask at 8 to 10 L/min 4. Perform a vaginal exam 5. Call the health care provider late decelerations continue

The nurse continues to assess a client who is in the late first stage of labor for progress and fetal well-being. At the last vaginal exam, the client was fully effaced, 8 cm dilated, vertex presentation, and station -1. Which observation would indicate that the fetus was in fetal distress?

Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable descending baseline.

The nurse is monitoring a pregnant woman in labor and notes the presence of variable decelerations on the fetal monitor tracing. Which finding should the nurse suspect, based on this observation?

Umbilical cord compression

During the initial maternal-infant bonding period after the delivery of the placenta, what is the nurse's primary responsibility?

Make sure the infant stays warm and is in no danger of slipping from the parent's grasp.

A newborn, at 1 minute after birth, has a heart rate of 140 beats per minute, a lusty cry, some flexion of extremities, and a pink body with blue extremities. Use the chart to calculate this newborn's 1-minute Apgar score. Refer to figure. Fill in the blank

8

The nurse is caring for a client who is in the active stage of labor. The nurse is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately?

Administer oxygen via face mask.

The nurse is caring for a human immunodeficiency virus (HIV)-positive pregnant client. Which procedure needs to be avoided to help prevent the transmission of HIV from the woman to her fetus during the intrapartum period?

Direct (internal) fetal heart rate monitoring.

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete uterine rupture occurred?

Decreasing blood pressure

Based on a complete assessment, the nurse has just instituted measures related to an occult prolapsed cord in a client just entering the second stage of labor. The sudden change of the labor plan has alarmed the client and her husband, who are anxiously asking what is happening and whether the baby is OK. Which response by the nurse will most likely reduce the fear and stress of the couple?

Explain to the couple what is happening, how it is being managed, and what they can do to help.

On assessment, the nurse discovers that a client in early second-stage labor has a prolapsed umbilical cord. The nurse turns the client to a modified Sims' position, starts oxygen at 8 to 10 L/min by mask, increases the rate of the intravenous fluids, contacts the health care provider and other staff, and explains the situation to the client. The nurse monitors the client by using which criteria to determine if interventions are effective?

Fetal monitor indicates a normal baseline rate and variability of the fetal heart rate.

The maternity nurse is assigned to care for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse is performing an assessment and determines that the dosage of the oxytocin should be decreased if which finding is noted?

Fetal tachycardia

The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a "tearing" sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which response to the client should the nurse make?

I can understand that you are fearful. We are doing everything possible for your baby.

The nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which action should the nurse do first?

Stop the oxytocin infusion

The nurse is caring for a client in labor who is receiving an oxytocin (Pitocin) infusion. The nurse notes the presence of tachycardia, decreased variability, and late decelerations on the fetal heart monitor. Which action should the nurse take immediately?

Stop the oxytocin infusion.

The nurse is caring for a client with a precipitous labor. What information should the nurse provide to the client regarding this type of labor?

The labor may last less than 3 hours

The nurse is performing an Apgar scoring on a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is irregular, and the infant has a weak cry. Muscle tone is active, the newborn grimaces when suctioned by the bulb syringe, and the skin color is pale. What Apgar score should the nurse document?

6

During the transition period of labor, the nurse notes that a client is having difficulty concentrating on her breathing technique. Her coach anxiously states that he just doesn't know how to help her. What would be an appropriate intervention by the nurse?

Keep them informed regarding the labor process and events using positive terms.

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. No help is available at the moment because of an emergency with another client at the distant end of the hall. Until help arrives, into which optimal position should the nurse place the client?

Lateral sims

The nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse should notify the health care provider (HCP) if which finding is noted?

Fetal tachycardia

The nurse is monitoring a client with an abruptio placentae for signs of disseminated intravascular coagulopathy (DIC). The nurse suspects the occurrence of DIC if which finding is noted?

Hematuria

The nurse is reviewing the antenatal history of a client in early labor. The nurse recognizes which factor documented in the history as having the most potential for causing neonatal sepsis after delivery?

History of substance abuse during pregnancy

The nurse answers a call light to the room of a woman who was just admitted to the hospital in early latent labor. The client is lying flat on her back on the bed. The husband states worriedly, "I think my wife is going into shock or something! She was just lying there, and she turned so pale and her hands are so clammy. She's dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure machine that the client's pulse is 58 beats per minute and her blood pressure is 90/50 mm Hg. How should the nurse interpret the client's signs/symptoms?

Impaired tissue perfusion related to hypotensive syndrome (vena cava syndrome)

The registered nurse asks the nursing student assigned to work in the labor and delivery room about the purpose of the placenta. Which response by the student nurse indicates an understanding of the purpose of the placenta?

It provides an exchange of nutrients and waste products between the mother and fetus.

The nurse is caring for a client in labor who has butorphanol tartrate (Stadol) prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?

Naloxone (Narcan)

A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?

Perform a manual sterile vaginal exam.

The nurse is monitoring a client with an abruptio placentae for signs of disseminated intravascular coagulopathy (DIC). Which sign would indicate the occurrence of DIC?

Petechiae, oozing from the injection sites, and hematuria.

A labor room nurse is assisting with a vaginal delivery. After the delivery of a viable newborn, the nurse notes that the umbilical cord lengthens, and a spurt of blood flows from the vagina. The nurse interprets which event as the correct interpretation of this data?

Placental separation

The labor room nurse is assisting with a vaginal delivery. After a client vaginally delivers a viable newborn, the nurse notes that the umbilical cord lengthens and a spurt of blood flows from the vagina. What development should the nurse interpret that this occurrence is indicative of?

Placental separation

A client who is at 35 weeks of gestation calls the nurse at the clinic and reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?

Premature rupture of the membranes

A client has arrived at the labor and delivery unit in active labor. The nursing assessment reveals a history of recurrent genital herpes and the presence of lesions in the genital tract. Which intervention should the nurse initiate?

Prepare the client for a cesarean delivery.

The nurse is caring for a client in labor. Immediately after delivering a normal healthy infant, the woman suddenly begins to complain of pain, and the nurse notes that the client is bleeding heavily from the vagina. The nurse suspects uterine inversion and should take which immediate action?

Prepares to administer a tocolytic

The nurse in the labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?

The passage of meconium

The nurse is assisting with caring for a woman in labor who is receiving oxytocin (Pitocin) by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?

Three to 5 contractions in a 10-minute period, with resultant cervical dilation.

The medication magnesium sulfate is started by intravenous (IV) infusion for a woman experiencing preterm labor. Which are the adverse effects of the medication? Select all that apply.

Tremors Headache Nervousness

The nurse is monitoring the status of client in active labor. The nurse interprets that which finding would be least consistent with dystocia?

Progressive changes in the cervix

The nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in caring for this client?

Provide pain-relief measures.

A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. What is the priority nursing action?

Assess the fetal heart rate

A client in labor is experiencing dystocia. In delivering care to this client, the nurse would place highest priority on which ongoing nursing intervention?

Assessment of fetal status and the physical and emotional condition of the mother

A priority for a client diagnosed with placental abruption is to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which sign is noted?

Presence of accelerations in the fetal heart rate.

A term client is admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the health care provider regarding which documented finding to verify the oxytocin induction?

Previous classic vertical uterine incision

A 30-week gestation client is admitted to the maternity unit in preterm labor. Betamethasone is prescribed to be administered and the client asks the nurse about the purpose of the medication. What should the nurse tell the client is the purpose for this medication?

Promote fetal lung maturity.

The nurse performs a vaginal assessment of a pregnant client in labor. On assessment the nurse notes the presence of the umbilical cord protruding from the vagina. Which action should the nurse take immediately?

Place a gloved hand into the vagina and hold the presenting part off the umbilical cord.