OB - Exam 2

The nurse is caring for a client in labor experiencing a prolapsed umbilical cord. The nurse anticipates that the fetal heart rate pattern will likely show A. early decelerations B. variable decelerations C. late decelerations D. normal variability

B. variable decelerations

The nurse is performing a prenatal assessment on a pregnant client. The nurse would plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? A. the client is 28 years of age B. this is the second pregnancy C. the client has a history of hypertension D. the client performs moderate exercise on a regular daily schedule

C. the client has a history of hypertension

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? A. changes in vital signs B. signs of heavy bleeding C. complaints of intense pain D. complaints of a tearing sensation

A. changes in vital signs

The nurse is monitoring a postpartum client, who delivered 1 hour ago and received epidural anesthesia for delivery, for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? A. changes in vital sings B. signs of heavy bruising C. complaints of intense pain D. complaints of a tearing sensation

A. changes in vital signs

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention would the nurse prepare the client for? A. delivery of the fetus B. strict monitoring of intake and output C. complete bed rest for the remainder of the pregnancy D. the need for weekly monitoring of coagulation studies until the time of delivery

A. delivery of the fetus

The nurse in a labor room is performing a vaginal assessment on the pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? A. gently push the cord into the vagina B. place the client in trendelenburg's position C. find the closest telephone and page the PHCP STAT D. call the delivery room to notify the staff tat the client will be transported immediately

B. place the client in trendelenburg's position

The nurse is caring for a client receiving an intravenous oxytocin infusion for the induction of labor. The nurse notes the client's fundus has been contracting continuously for the past 5 minutes. An assessment of the fetal heart rate reveals 95 bpm. Which of the following should be the nurses initial action? A. Place the client in a trendelenburg position B. Stop the oxytocin infusion C. Administer oxygen via face mask D. Administer intravenous fluids at a high rate

B. stop the oxytocin infusion

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding would the nurse expect to note if this condition is present? A. soft abdomen B. uterine tenderness C. absence of abdominal pain D. painless, bright red vaginal bleeding

B. uterine tenderness

A client arrives at a birthing center in active labor. Following examination, it is determined that the client membranes are still intact and the client is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? SATA A. less pressure on the cervix B. decreased number of contractions C. increased efficiency of contractions D. the need for increased blood pressure monitoring E. the need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

C. increased efficiency of contractions E. the need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm but that bleeding is excessive. Which would be the initial nursing action? A. record the findings B. massage the fundus C. notify the obstetrician (OB) D. place the client in trendelenburg's position

C. notify the obstetrician (OB)

A delivery room nurse is caring for a client in labor. The client tells the nurse about feeling something coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse would immediately place the client in which position? A. prone B. supine C. on the side D. reverse trendelenburgs

C. on the side

A pregnant client being admitted to the labor room tells the nurse about feeling a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the FHR is 90 bpm and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? A. place the client in a high-fowlers position B. palpate and evaluate contractions while administering a tocolytic C. wrap the cod loosely in a sterile towel saturated with warm sterile normal saline D. start an IV line with fluids to be administered at a keep-vein-open (KVO) rate only

C. wrap the cod loosely in a sterile towel saturated with warm sterile normal saline

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm but that bleeding is excessive. Which would be the initial nursing action? A. record the findings B. massage the fundus C. place the client in trendelenburg's position D. notify the PHCP

D. notify the PHCP

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? A. document the findings B. reassess the client in 2 hours C. encourage increased oral intake of fluids D. notify the PHCP

D. notify the PHCP

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted? A. back pain B. abdominal pain C. painful vaginal bleeding D. painless vaginal bleeding

D. painless vaginal bleeding

The nurse is monitoring a client in labor whose membranes ruptures spontaneously. What is the initial nursing action? A. determine the FHR B. provide peripads for the client C. take the client's blood pressure D. not the amount, color, and odor of the amniotic fluid

A. determine the FHR

A 38 week pregnant woman comes into the emergency department complaining of vaginal bleeding. The client is not in obvious distress or pain. Which statement by the client would lead the nurse to suspect placenta previa? A. "I don't feel any pain at all, it's just the bleeding that concerns me" B. "I feel like I'm about to go into labor, my tummy is starting to contract" C. "I started bleeding when i picked up my 3 year old son, who weighs 32 pounds" D. "I feel like i'm about to vomit"

A. "I don't feel any pain at all, it's just the bleeding that concerns me"

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which occurred? A. forceps delivery B. Schultz presentation C. hypotonic contractions D. weak bearing-down efforts

A. forceps delivery

The nurse working in the maternity ward is caring for a 24 hour postpartum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little to the right. The initial action for the nurse is to: A. Check for bladder distention B. Check the client's blood pressure C. Check if the client has been given Oxytocin D. Check the pad count

A. Check for bladder distention

The nurse is caring for assigned clients. The nurse should recognize that the patient at most significant risk for postpartum hemorrhage (PPH) is the client who has which of the following? A. Uterine atony and delivered with the assistance of forceps B. Postpartum urinary incontinence and diuresis C. An active outbreak of genital herpes and had a cesarean section D. Gestational diabetes and has postpartum hyperglycemia

A. Uterine atony and delivered with the assistance of forceps

The nurse would take which nursing actions when caring for a postpartum client who begins to hemorrhage? SATA A. assess for uterine atony B. prepare to administer blood or blood products as prescribed C. insert an indwelling urinary catheter to monitor kidney perfusion D. administer 8-10 L/min of oxygen via non-rebreather face mask E. administer uterotonic medications as prescribed to increase uterine tone

A. assess for uterine atony B. prepare to administer blood or blood products as prescribed C. insert an indwelling urinary catheter to monitor kidney perfusion D. administer 8-10 L/min of oxygen via non-rebreather face mask E. administer uterotonic medications as prescribed to increase uterine tone

The nurse assists the primary health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? A. assess the fetal heart rate B. check the clients temperature C. change the pads under the client D. check the clients respiratory rate

A. assess the fetal heart rate

The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? A. monitoring fetal status B. providing comfort measures C. changing the client's position frequently D. keeping the significant other informed of the progress of the labor

A. monitoring fetal status

A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa? A. the placenta is implanted in the lower uterine segment B. the greatest risk associated with this condition is chronic hypertension C. There are two placentas attached to the fetus located in the side of the uterine wall D. the placenta is half the size that it is expected to be, preventing a risk for deprivation of nutrients to the fetus

A. the placenta is implanted in the lower uterine segment

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? SATA A. uterine tenderness B. acute abdominal pain C. a hard, "board-like" abdomen D. painless, bright red vaginal bleeding E. increased uterine resting tone on fetal monitoring

A. uterine tenderness B. acute abdominal pain C. a hard, "board-like" abdomen E. increased uterine resting tone on fetal monitoring

Methylergonovine is prescribed for a client to treat postpartum hemorrhage. Before administering the medication, the nurse would contact the PHCP who prescribed the medication if which condition is documented in the client's medical history? A. hypotension B. hypothyroidism C. diabetes mellitus D. peripheral vascular disease

D. peripheral vascular disease

The nurse is caring for four 1-day postpartum clients. Which client assessment required the need for follow-up? A. the client with mild afterpains B. the client with a pulse rate of 60 bpm C. the client with colostrum discharge from both breasts/chest D. the client with lochia that is red and has a foul-smelling odor

D. the client with lochia that is red and has a foul-smelling odor

The nurse performs a postpartum assessment on a client who delivered a term newborn two hours ago. The nurse suspects that the client has developed postpartum hemorrhage. Which action should the nurse perform to confirm this finding? A. Assess the 24-hour intake and output B. Ask the client to turn to her side C. Assess the pulse for bradycardia D. Obtain orthostatic blood pressure

B. Ask the client to turn to her side

The nurse is caring for a client in labor who jut received epidural analgesia. The nurse should monitor the client for which adverse effects? A. Hypertension B. Bladder distention C. Hypothermia D. Precipitous labor

B. Bladder distention

The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take? A. Reposition the patient on her side B. Document the findings C. Discontinue oxytocin infusion D. Prepare for amnioinfusion

B. Document the findings

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? A. presence of dark red lochia B. palpation of the uterus as a firm, contracted ball C. palpation of the fundus at the level of the umbilicus D. the saturation of more than 1 peripad per hour

D. the saturation of more than 1 peripad per hour

The nurse is caring for a client who is six hours postpartum. The client informs the nurse that they have changed their per-pad four times in the last six hours. The nurse should take which action? A. Document the finding as expected B. Massage the client's fundus C. Assess the client for hemorrhage D. Ambulate the client to the bathroom

B. Massage the client's fundus

The nurse is in the postpartum unit assessing a client who gave birth 2 hours ago. The nurse notes that the client's fundus is soft and boggy. Her perineal pads have been changed twice over the past 2 hours. What is the initial action of the nurse? A. Apply pressure on the fundus B. Massage the fundus until it is firm C. Notify the physician D. Elevate the client's legs

B. Massage the fundus until it is firm

The nurse is assessing a client in the labor and delivery department. She notes that the client's abdomen remains hard between contractions and that the fetal heart rate is 99 bpm. Which nursing diagnosis should take priority? A. Fluid and electrolyte imbalance B. Risk for fetal demise C. Ineffective breathing problem D. Alteration in comfort

B. Risk for fetal demise

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock? A. complaints of abdominal cramping B. an increased pulse rate of 80-120 bpm C. complaints of feeling tired yet is feeling hungry D. an increase in respiratory rate from 18-22 breaths/min

B. an increased pulse rate of 80-120 bpm

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? A. identify the types of accelerations B. assess the baseline FHR C. determine the intensity of the contractions D. determine the frequency of the contractions

B. assess the baseline FHR

Methylergonovine is prescribed for a client to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? A. uterine tone B. blood pressure C. amount of lochia D. deep tendon reflexes

B. blood pressure

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A. infection B. hemorrhage C. chronic hypertension D. disseminated intravascular coagulation

B. hemorrhage

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? A. providing comfort measures B. monitoring FHR C. changing the client's position frequently D. keeping the significant other informed of the progress of the labor

B. monitoring FHR

A woman was admitted to the obstetric unit in active labor and has had a frank rupture of membranes. A fetal scalp electrode and intrauterine pressure catheter were inserted promptly. The woman had progressed to 8-cm dilation when the nurse noticed abrupt decreases in the fetal heart rate of 15-20 bpm that quickly returned to baseline. The changes in fetal heart rate occurred with and without contractions. At this point, the nurse should prepare to initiate a client teaching about the possibility of which procedure? A. High forceps delivery B. Oxytocin induction C. Amnioinfusion D. Cesarean birth

C. Amnioinfusion

While assessing a laboring mother during a contraction, the nurse notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A. Late deceleration B. Moderate variability C. Early deceleration D. Marked variability

C. Early deceleration

A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, delivery, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly thereafter, you enter. During your discussion, the client states the HCP "went to order oxytocin". In anticipation of that order, you understand this client's oxytocin will be administered via which route of administration? A. Intramuscular administration B. Intravenous administration via mainline infusion using an infusion pump C. Intravenous administration via piggyback using an infusion pump

C. Intravenous administration via piggyback using an infusion pump

A pregnant client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum the client's systolic blood pressure has dropped 20 points, the diastolic blood pressure has dropped 10 points, and the client's pulse is 120 bpm. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the PHCP what is the nurses next action? A. reassure the client B. monitor fundal height C. apply perineal pressure D. prepare the client for surgery

D. prepare the client for surgery

The client is undergoing labor in the delivery room. The fetal monitor shows that there are late decelerations. What is the initial action of the nurse? A. Call the doctor immediately B. Let the client deep-breathe slowly and relax C. Let the client lie on her left side D. Prepare for Cesarean delivery

C. Lie the client on her left side

The nurse is caring for a client in labor and discovers the client has a completely prolapsed umbilical cord. The nurse should take which action? A. Encourage the client to push at the next contraction B. Administer nasal cannula oxygen at 2 liters/minute C. Position the client knee to chest D. Obtain a prescription for oxytocin

C. Position the client knee to chest

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A. a primiparous client who delivered 4 hours ago B. a multiparous client who delivered 6 hours ago C. a multiparous client who delivered a large baby after oxytocin induction D. a primiparous client who delivered 6 hours ago and had epidural anesthesia

C. a multiparous client who delivered a large baby after oxytocin induction

A pregnant client at 35 weeks gestation is transferred to the maternity unit from the emergency department, after being treated for minor injuries sustained in a motor vehicle crash. The nurse's priority will be to assess for which complication? A. placenta previa B. polyhydraminos C. abruptio placentae D. gestational hypertension

C. abruptio placentae

The nurse is preparing to care for a client in labor. The primary health care provider has prescribed an IV infusion of oxytocin. The nurse would ensure that which is implemented before the beginning of the infusion? A. an IV infusion of antibiotics B. placing the client on complete bed rest C. continuous electronic fetal monitoring D. placing a code cart at the client's bedside

C. continuous electronic fetal monitoring

The nurse in the postpartum unit notes that a new parent was given methylergonovine intramuscularly following delivery. What assessment finding indicates that the medication was effective? A. lochia that is serous B. normal blood pressure C. decreased uterine bleeding D. decreased uterine contractions

C. decreased uterine bleeding

Methylergonovine is prescribed for a client with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse would check which most important client parameter? A. lochial flow B. urine output C. temperature D. blood pressure

D. blood pressure

The nurse observes the fetal heart monitor (FHR) tracing showing variable decelerations. Which of the following could cause this FHR pattern? A. fetal movement B. fetal head compression C. compression of the maternal vena cava D. prolapsed umbilical cord

D. prolapsed umbilical cord

A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following, should be the nurse's initial action? A. Assess the color of the amniotic fluid B. Perform a vaginal examination to assess the cervix for dilation C. Inform the client she is now on strict bed rest until further notice D. Assess the fetal heart tones

D. Assess the fetal heart tones

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? A. place the client in trendelenburg's position B. administer oxygen to the client by face mask C. contact the primary health care provider (PHCP) D. document the findings and continue to monitor fetal patterns

D. document the findings and continue to monitor fetal patterns

The nurse is caring for a client who has just given birth and is resting in the postpartum unit when suddenly she feels a sharp pain in the chest and is having difficulty breathing. Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate of 24. She is suspected of having a pulmonary embolism. What should be the initial action of the nurse? A. Start a peripheral vascular access device B. Monitor the client's blood pressure C. Draw up morphine sulfate D. Give oxygen via face mask at 8-10 liters per minute

D. Give oxygen via face mask at 8-10 liters per minute

The nurse is performing a vaginal assessment of a pregnant client who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? A. administer oxygen to the client B. transport the client to the delivery room C. place an external fetal monitor on the client D. exert upward pressure against the presenting part

D. exert upward pressure against the presenting part