NUR 410 MATERNITY PREPU

A pregnant client at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse?

"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."

A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching?

"It's okay for my husband and me to have sexual intercourse."

During active labor, the nurse notes a decrease in the baby's fetal heart rate and consults with the health care provider. The provider concurs and prescribes application of oxygen via mask, increase in IV fluids, and repositioning. The nurse should communicate which piece of information to the woman when she protests about being "tied down" in bed with IVs?

"Remember, the goal is to increase the FHR so a healthy infant can be born."

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth?

11

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion.

A pregnant patient is diagnosed with placenta previa. Which action should the nurse implement immediately for this patient?

Assess fetal heart sounds with an external monitor.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds.

During a prenatal ultrasound, the client is discovered to have a placenta succenturiata. Following delivery of the fetus and placenta, which nursing assessment is most important?

Assessment for hemorrhage

When educating the post-term pregnant client, what should the nurse be sure to include to prevent fetal complications?

Be sure to monitor fetal movements daily.

A pregnant client mentions to the nurse that a friend has given her a variety of herbs to use during her upcoming labor to help manage pain. Specifically, she gave her chamomile tea, raspberry leaf tea, skullcap, catnip, jasmine, lavender, and black cohosh. Which of these should the nurse encourage the client not to take because of the risk of acute toxic effects such as cerebrovascular accident?

Black cohosh

Before calling the primary care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder.

A woman at 32 weeks' gestation just experienced rupture of her membranes. She asks the nurse what could cause this to happen and the nurse's explanation would include which risk factors? Select all that apply.

Cigarette smoking Multifetal pregnancies Amniocentesis

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?

Depressed deep tendon reflexes

The nurse is monitoring a woman who is receiving oxytocin IV to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?

Discontinue the oxytocin infusion.

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?

Fetal heart tones

A woman who is 42 weeks pregnant comes to the clinic. During the visit, which assessment should be prioritize?

Fetal heart tones

A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms?

If rhythmical, they could indicate preterm labor.

A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which of the following tests would the nurse expect to be used to predict fetal lung maturity when the client goes into labor?

Lecithin/sphingomyelin ratio

A nurse is reviewing the medical record of a pregnant client. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which condition?

Low-lying placenta

A nurse is caring for a client at 30 weeks' gestation who had preterm premature rupture of membranes (PROM) 25 hours ago. The client has a temperature of 102°F (38.9°C) and a foul-smelling odor from the vagina. Which medication order should the nurse question?

Magnesium sulfate 2 GM IV/hr

The nurse is assessing a multipara client at 28 weeks' gestation who may be experiencing labor. Which findings should the nurse prioritize?

Positive fetal fibronectin

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta

A pregnant client arrives at the clinic for a regular antenatal check-up. Examinations and weight recording reveal a slow fetal weight gain. About which of the following pregnancy-related risks should the nurse alert the client?

Preterm labor

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

Respiratory depression, hypotension, absent tendon reflexes

A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client?

Risk for fetal infection related to early rupture of membranes

A nurse is caring for a client in labor who has been diagnosed with placental problems. Which of the following is indicative of placenta succenturiata?

Small accessory lobes develop in the membranes at a distance from the main placenta.

A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?

Umbilical cord prolapse

The nurse manager is reviewing all the L & D clients on the unit in order to prepare assignments to the nursing staff. For which clients would augmentation of labor with oxytocin be considered contraindicated or used cautiously? Select all that apply.

a 33-year-old female who is 32 weeks' gestation in labor with twins a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours a 33-year-old female who is 32 weeks' gestation in labor with twins a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the health care provider

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy

A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is post-term and has oligohydramnios. What does this increase the risk of during birth?

cord compression

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

foul odor

The nurse identifies a nursing diagnosis of Risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

foul odor

Which assessment finding will alert the nurse to be on the lookout for possible placental abruption during labor?

gestational hypertension

A client has been admitted with placental abruption. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae?

grade 2

A nurse is describing the risks associated with post-term pregnancies as part of an inservice presentation. The nurse determines that more teaching is needed when the group identifies which factor as an underlying reason for problems in the fetus?

increased amniotic fluid volume

A nurse is explaining to a group of nurses new to the labor and birth unit about about methods used for cervical ripening. The group demonstrates understanding of the information when they identify which method as a mechanical one?

laminaria

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?

macrosomia

The nurse who works at the local health department is preparing to give a talk on post-term pregnancies. She wants to include the fetal risks. Which risks should she include? Select all that apply.

macrosomia shoulder dystocia brachial plexus injuries cephalopelvic disproportion

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?

magnesium sulfate

A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply.

nifedipine magnesium sulfate indomethacin

A patient who experiences premature rupture of membranes can expect to be put on pelvic rest. The nurse should explain to the patient that pelvic rest involves which of the following?

placing nothing in the vagina

A patient who is at 7 months' gestation presents to the emergency department with reports of a large gush and continuous leaking of fluid from her vagina. She does have some slight pelvic pressure but denies any contractions. This patient is showing clinical signs of which of the following?

premature rupture of membranes

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction?

shortened

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?

tocolytic therapy

A pregnant woman at the emergency department informs staff that she is at least 2 weeks past her due date. The physician begins to perform several tests to determine fetal age. The nurse anticipates that the woman's amniotic fluid volume will be decreased. How would the nurse measure the amniotic fluid in this situation?

ultrasound

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention?

urine output of 20 mL/hour

A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect?

uterine hyperstimulation