PNU 133 PassPoint PrepU Intrapartum

A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." Which statement made by the nurse is therapeutic?

"Did I hear you say you sustained this burns from hot water application to the buttocks?"

A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion?

135 beats/minute

A health care provider has ordered an IV of 5% dextrose in lactated Ringer's solution at 125 mL/hour. The IV tubing delivers 10 drops per mL. How many drops per minute should fall into the drip chamber?

20 to 21

A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?

42 drops/minute

Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

An increased sense of rectal pressure

A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?

Ask the client about her most recent blood glucose levels.

Which care intervention is appropriate for the fourth stage of labor?

Assessing lochia and the location and consistency of the fundus

A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best?

Assisting the client to ambulate in the room

The nurse is caring for a 28-year-old primigravida who is reporting severe back labor. Which nursing intervention is most effective in improving the comfort of the client?

Back massage with sacral pressure

A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.

Check vital signs. Check the fundal height. Notify the RN.

An actively laboring client who is 6 cm dilated and who attended natural childbirth classes asks the nurse for pain medication. What is the most appropriate action by the nurse?

Contact the health care provider for pain medication.

Which action should the nurse take to promote the descent of the fetus's presenting part?

Encourage the client to void every 2 hours.

The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.

A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response?

Explain to the client that the feeling is normal during this stage.

The nurse is reviewing a client's prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth?

History of postpartum hemorrhage (PPH)

A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be mostappropriate?

Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.

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 husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time?

Instruct the husband on touch, massage, and breathing patterns.

The nurse receives a client in the postanesthetic care unit (PACU) following a cesarean birth. Which actions should the nurse take immediately upon receiving the client? Select all that apply.

Monitor vital signs every 15 minutes. Check abdominal dressing for bleeding. Assess catheter and urine output. Check level of consciousness.

A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority?

Note the color, amount, and odor of the fluid.

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions?

Notify the obstetrician

After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next?

Prepare for immediate delivery of the baby

A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?

Prepare the client and partner for a cesarean birth as soon as possible.

The nurse is caring for a client in the second stage of labor. The client provided the healthcare team with a birth plan that included no use of analgesia. The client is having strong contractions with pain at 10 out of 10 and asks for something for pain. What is the nurse's bestaction?

Remind the client of the desire outlined in the birth plan and clarify if analgesia is desired.

The nurse places a client in labor in a supine position to obtain a good monitor tracing when suddenly, the client becomes light-headed and diaphoretic. Which of the following should be the nurse's first action?

Reposition the client to her left side.

A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take?

Reposition the client to left lateral position.

The client and her partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence?

The national standards of practice were met when providing care.

A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?

The time of membrane rupture

A client in labor is receiving magnesium sulfate as an intravenous infusion. Which medication should the nurse ensure is at the bedside while the magnesium sulfate is being infused?

calcium gluconate

A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate?

cesarean delivery

A pregnant client with a history of cardiac dysfunction has been taking propranolol, a beta-adrenergic blocker, to treat hypertension. During labor, the nurse should assess for what adverse effect of this drug?

hypotension

A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered?

lateral

A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?

physician

Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which concerns?

Headache, blurred vision, and facial and extremity swelling

The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN?

A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.

Assessing a client progressing through labor reveals the findings below. Order them in the most likely sequence in which they would have occurred. All options must be used.

strong Braxton Hicks contractions mild contractions lasting 20 to 40 seconds cervical dilation of 4 cm 100% cervical effacement uncontrollable urge to push

A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective?

"Braxton Hicks contractions begin in the abdomen and remain irregular."

The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first?

"What is your expected due date?"

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 beststrategy 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."

The nurse admits a client in active labor at 38 weeks gestation. The client says to the nurse, "I was not expecting to go into labor so soon, so I did not have time to shave down there." How should the nurse respond?

"It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?"

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 client has received dinoprostone to help ripen her cervix. What should the nurse do to determine effectiveness of the drug?

Assess for ripening and softening of the cervix.

A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor?

Assist the client in performing effleurage.

A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in the fetal heart rate (FHR). After notifying the registered nurse in charge, what should the nurse do next?

Change the client's position.

A nurse is caring for a primigravida client who is in labor. When does the nurse suspect the client has progressed to the second stage of labor?

Client has an uncontrollable urge to bear down.

The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications?

Encourage the client to practice breathing exercises to decrease the urge to push.

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but reports mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?

Latent phase

Which intervention should be included in the safety plan for the maternal- infant unit?

Making sure that the spouse or significant other wears an identification band

A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next?

Massage the fundus.

A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?

Massage the fundus.

A client in labor has been given an epidural anesthetic. When collecting data on the client immediately following the epidural administration, which finding would be most important for the nurse to report?

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene?

Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output

Which of the following health conditions makes it necessary for the nurse to check blood pressure frequently during labor?

Preeclampsia

A nurse is caring for a client in active labor who is crying and asking for something for pain. Her medical record shows that she does not tolerate prescribed opioid analgesics. Which of the following nonpharmacologic interventions might be helpful to this client?

Provide back massage to the client.

A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest?

Provide helpful distractions.

A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress?

blood pressure of 146/94 mm Hg

A client at 42 weeks' gestation is 3 cm dilated and 30% effaced with membranes intact and the fetus at +2 station. Fetal heart rate (FHR) is 140 to 150 beats/minute. After 2 hours, the nurse notes on the external fetal monitor that for the past 10 minutes, the FHR ranged from 160 to 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. The nurse suspects fetal hypoxia based on which finding?

excessive fetal activity and fetal tachycardia

A pregnant client has a total hemoglobin level of 9 g/dL. The nurse understands that the client is at greatest risk for which condition during the intrapartum period?

fetal distress

A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?

fetal heart rate of 80 beats/minute

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which bestdescribes why the nurse is asking questions about the family's birth plan?

recognizing the family as active participants in their care