OB exam #2 1

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

Position the client on her side

A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?

☆ Supporting the infant during birth.

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

☆ The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.

A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

100

1. A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority?

dry new born

1. nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?

headache

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

☆ "Take a deep, cleansing breath before and after each contraction."

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

☆ "You will experience a surge of energy."

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?

☆ A client who has preeclampsia and reports epigastric pain and unresolved headache.

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

☆ A large amount of vaginal bleeding without pain.

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

☆ Check the fetal heart rate pattern.

There are different factors pertaining to False and True labor. Please check all that apply to True labor:

☆ Contractions develop a regular pattern that are more intense and frequent ☆ Progressive effacement and dilation of the cervix occurs ☆ True labor cannot be stopped

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged, and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

☆ Fetal position is persistent occiput posterior.

A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

☆ Lecithin/sphingomyelin (L/S) ratio of 2:1

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

☆ Place the client in a knee-chest or Trendelenburg position.