NCLEX on intrapartum

a 30 week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing Department of the hospital. The nurse prepares the client for which expected diagnostic procedure

contraction stress test

the nurse is monitoring a client in active labor no said they client is having contractions every 3 minutes that last 45 seconds. The nurse notes said they fetal heart rate between contractions is 100 beats per minute. Which action is appropriate

notified the registered nurse

the nurse knows that a client in labor has foul-smelling amniotic fluid and maternal temperature of 101 ° F and a urine output of 150 ml during the past 2 hours. The nurse should do which action at this time

notify the registered nurse of a possible maternal infection

the nurse is reviewing the record of a client in the labor room and no set the nurse Midwife has documented that the fetus's at minus one station. The nurse determines that the fetal presenting part is which position

one centimeter by the ischial spine

when examining the umbilical cord immediately after birth which blood vessels are present in a normal umbilical cord

one vein two arteries

the nurse should prepare to give a prescribed oxytocic medication after delivery of which

placentae

after the client vaginally delivers a viable newborn the nurse sees the umbilical cord lengthened and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition

placental separation

the nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which finding is least likely associated with DIC

swelling of the calf of one leg

a client has just had surgery to deliver a non viable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams God just let me die now which problem would direct care for this client

the client feels helpless about the situation

the nurse is assisting in the admission of a woman for induction of Labor. The nurse should contact the healthcare provider before proceeding with the induction if which conditions are noted during the assessment

the fetus is in the breech position lesions are present on the perineum the fetus is not settled into the pelvis

a client is undergoing electronic fetal monitoring and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands is procedure

what an effective way to record my baby's heart rate

a client tells the nurse her contractions are getting stronger and that she is getting tired. She appears Restless asked the nurse not to leave her alone and states I can't take it anymore. Based on the client's Behavior the nurse should suspect the client is how far dilated

8to 10 cm

the nurse is assigned to care for a client who is in early labor. When collecting data from the client which should the nurse check first

Baseline fetal heart rate

the nurse is assisting in performing Leopold's Maneuvers. Declined ask the purpose of the procedure. How should the nurse respond to the client

Leopold's Maneuvers are used to determine fetal position

the nurse is assigned to assist in caring for a client in labor. The nurse would determine that which sign/symptom would least likely indicate dystocia

Progressive changes in the cervix

the client who is being prepared for a cesarean deliveries brought to the the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus the nurse should place the client in which position

Supine position with the wedge under the right hip

a pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure

a cesarean birth

the client is admitted to the labor Suite complaining of painless vaginal bleeding. The nurse assist with examination of the clot knowing that which routine labor procedure is contraindicated

a manual pelvic examination

a client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickle cell crisis. The nurse should take which action to assisted preventing a crisis from occurring during labor

administer oxygen as prescribed

the nurse is assisting with monitoring a client in labor is told that they client cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's physiological status the nurse anticipates the client reflect which attitude

excitement

the nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip

maternal vital signs

the nurse is assigned to care for a client experiencing dystocia. Which would be the highest priority in planning care

monitoring for changes in the physical and emotional conditions of the mother and fetus

the nurse tells a client she is now beginning the second stage of Labor. The nurse recognizes the client understands the occurrence of the stage when they client makes which statement

my cervix is completely dilated

the nurse is assisting in the care of a woman in labor should focus primarily on which quad at the time of delivery

newborn

the nurse is providing emergency measures to a pregnant client with a prolapsed cord. They mother becomes anxious and frightening says to the nurse why are all these people in here? is my baby going to be all right? Which appropriately describes the mother's problem at this time

fear about what is happening

the nurse observes that a client in the transition stage of Labor is crying out in pain with pushing efforts. The nurse recognizes this Behavior as indicated of which response

fear of losing control

the nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted

fetal tachycardia

which would be the appropriate method to use to deliver the placenta after a precipitate delivery

gently guide the placenta out after a spontaneous separation

the nurse is asked to assist the primary health care provider in performing Leopold's maneuver on a client. Which nursing intervention should be implemented before this procedure is performed

have they client into her bladder

the nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical OS. The nurse understands that the client is experiencing which condition

complete placenta previa

for the previous four hours a client in labor has been experiencing contractions every 2 minutes lasting 60 to 70 seconds and strong to palpation. She is dilated 2 cm and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia

hypertonic

a prenatal client with severe abdominal pain is admitted to the labor and birthing Department. Which data indicates to the nurse the presence of concealed bleeding

increase in fundal height

a client arrives at the birthing center in active labor. Her membranes are still intact and the nurse Midwife performs aniotomy. the nurse explains to the client that this procedure will most likely have which effect

increased efficiency of contractions

the nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client the nurse places which items at the client's bedside

intravenous supplies

the nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 centimeters dilated and is experiencing precipitous labor which is the priority nursing action

keep the client in a sideline position

the nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 centimeters dilated and is experiencing precipitous labor. Which is the priority nursing action

keep the clock in a sideline position

the nurse is caring for a woman in labor who is experiencing a precipitant delivery. Until help arrives the nurse places the client into which optimal position

lateral Sims

a pregnant client at 36 weeks gestation experiences painless bleeding is admitted to the labor room. Which action should the nurse include in the plan of care

maintain complete bed rest, monitor IV fluid intake, and monitor the fetal heart rate

the nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate-intensity. The nurse should do which at this time

continue moderating the client because they data reflect acceptable progress

the nurse is assisting in preparing to care for a client undergoing an induction of Labor with an infusion of oxytocin. The nurse should include which in the plan of care

maintain continuous electronic fetal monitoring

the client is in the second stage of Labor. As the baby begins to Crown, the healthcare provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take

continue to assess Vital Signs and fetal heart rate the same as before the nerve block

declined is having moderate contractions that are occurring every 5 minutes and Lasting 60 seconds. The fetal heart rate is 150 beats per minute and regular. Based on these findings what is the appropriate nursing action

continue to monitor the client

the nurse is assigned to care for a prima gravida who is having a precipitant delivery. Which maternal finding does the nurse expect to note

decrease periods of uterine relaxation between contractions

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

decreasing blood pressure

a primigravid is membranes rupture spontaneously. Which action should the nurse take first

determine the fetal heart rate

the nurses monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action

determine the fetal heart rate

the nurse in the labor room is caring for a client in the first stage of Labor. When monitoring the fetal patterns the nurse knows an early deceleration of the fetal heart rate on the monitor strip. Which is the appropriate nursing action

document the findings and continue to monitor the fetal patterns

the nurse in the labor room is assisting in caring for a client in active stage of Labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding the nurse prepares for which appropriate nursing action

documenting the findings and continue to monitor the fetal patterns

the nurse prepares to explain the purpose of effleurage in early labor. Which explanation by the nurse describes effleurage?

effleurage is light stroking of the abdomen to facilitate relaxation during labor

a client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety

encourage the client to discuss her concerns and desires regarding anesthesia options

the nurse is caring for a client diagnosed with abruptio placentae. During labor the priority nursing action would be to monitor which criteria

all Vital Signs especially heart rate and blood pressure

a mother experiencing dystocia looks alarmed and ask what's going on? why are you all poking and prodding? is my baby okay? based on the client's questions the nurse understands that the client is experiencing which problem

anxiety and fear

the nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced the same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care

anxiety related to a slow progress of Labor

the nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note

bright red vaginal bleeding soft, relaxed, non-tender uterus

the nurse in the delivery room is assisting with the delivery of a newborn. which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery

changes in the shape of the uterus

the nursing in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and it is ready for delivery

changes in the shape of the uterus

a client is brought to the labor unit. As the nurse is attaching a fetal heart monitor they client's membranes rupture spontaneously. What should be the nurse's immediate action

check the fetal heart rate

the nurse assist the nurse midwife in examining the client. The Midwife documents be following data cervix 80% effaced and 3cm dilated, vertex presentation -2 station, membranes ruptured. The nurse anticipates that the Midwife will prescribe which action for the client

complete bed rest

a client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes and the fetus is currently at station zero. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent non reassuring fetal heart rate pattern is present. Which nursing action is appropriate

prepare the client for cesarean delivery

During the intrapartum period the nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intervenience fluid intake and oxygen consumption to primarily accomplish which result

prevent dehydration and hypoxemia

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

provide pain relief measures

immediately following the delivery of a newborn the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta

pull gently on the cord as a mother bear down

if a precipitate delivery is imminent which would be the appropriate nursing action

put on sterile gloves and gently got the baby's head and shoulders out

the nurse caring for a client following a precipitant delivery. In addition to fundal massage the nurse understands that which nursing action will promote the birth of the placenta

putting the baby to the mother's breast and letting the baby suck

the nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder and declined ask the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheters primary purpose

reduce the risk of injuring the bladder during the surgery

a client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100 degrees Fahrenheit and ate 2 hours ago. Which intervention has priority

report the time of last food intake to the healthcare provider

a client who is a prima gravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse

respirations of 10 breaths per minute

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. the nurse determines which physiological need is primary to the client at this time

rest between contractions

the nurse is caring for a woman and the labor room. The healthcare provider prescribes and oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication

resting intervals at 50 seconds

a pregnant client with severe uterine bleeding is admitted to the labor and birthing Department. Which data should best alert the nurse to early signs of hypovolemic shock

restlessness and agitation

the nurse is assisting in caring for a client in labor. Which data collection finding by the nurse would place the client at risk for uterine rupture

shoulder dystocia

the nurse is caring for a client who is in labor. The nurse tree checks the client's blood pressure and knows that it has dropped. To decrease the incidence of supine hypotension the nurse should encourage the client to remain in which position

sideline

the nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia

signs of fetal distress high level of maternal anxiety failure of the fetus to descend

the nurse assist in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which

signs of shock

the nurse caring for a client who is receiving oxytocin for the induction of Labor notes a non reassuring fetal heart rate pattern on the fetal monitor. On the basis of this finding which is the nurses priority action

stop the oxytocin infusion