NCLEX REVIEW Intrapartum Period
The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict?
"I will make every effort to work with your cultural beliefs."
A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response?
"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 ml normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using a whole number.
50
The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply.
Encourage ambulation. Suggest a shower or bath. Offer the use of a yoga ball.
A client is attempting vaginal delivery after cesarean section (VBAC). Contractions are 2 minutes apart and last 75 to 90 seconds. The client reports a "sharp, tearing" pain and the electronic fetal monitor (EFM) no longer is recording contractions. What is the priority nursing action?
Notify the health care provider.
A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), what should the nurse do?
Turn the client to her side.
A client who is 29 weeks pregnant comes to the labor and childbirth unit. She states that she is having contractions every 8 minutes. The client is also 3 cm dilated. Which can the nurse expect to administer? Select all that apply.
a β-2 agonist betamethasone intravenous fluids
A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?
blue
After explaining about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed?
"I should try to push with each contraction."
A client who is 5 cm dilated reports that she has the urge to push. Which is the appropriate response by the nurse?
Have client blow out breath to keep from pushing.
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time?
Instruct the partner on touch, massage, and breathing patterns.
The nurse has administered promethazine intravenously to a client in active labor. The drug has had the desired effect when the nurse notes:
decreased nausea and vomiting.
After several hours of induction with intravenous oxytocin administered along with a primary intravenous solution of lactated Ringer's solution, assessment of a primigravida at 42 weeks' gestation reveals a fetal heart rate near the baseline at 120 bpm and strong contractions occurring every 2 to 2.5 minutes and lasting 90 to 100 seconds. In what order from first to last should the nurse perform the required actions? All options must be used.
Stop the intravenous flow of oxytocin. Position the client in a lateral position. Administer oxygen at a rate of 8 to 10 L/min. Contact the primary care provider for further prescriptions.
Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate?
Give the client a paper bag and have her breathe into it.
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?
The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.
A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?
chaplain, because his educational background includes strategies for handling grief
A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which problem?
conjunctivitis
A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
oxytocin 30 units in 500 ml D5W
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding?
passage of meconium by the fetus
The nurse is preparing to assist the health care provider (HCP) with a cervical check for a client whose membranes have ruptured. What equipment should the nurse have ready for the HCP? Select all that apply.
sterile gloves sterile lubricant
