Pregnancy, Labour, Childbirth, Postpartum - Uncomplicated

A client's membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?

Auscultating the fetal heart rate

During a routine second-trimester visit to the prenatal clinic a client expresses concern about gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response?

"If you add 340 calories a day to your regular diet, you won't become overweight."

What should a nurse suggest to a pregnant client that might help overcome first-trimester morning sickness?

"Eat protein before bedtime."

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do?

Apply cold packs and a snugly fitting bra.

A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report:

Leakage of fluid from the vagina

What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement?

Apply cold packs to the breasts frequently.

The fetus of a client in labor is in the left occiput posterior position. What should the nurse advise the client's partner to do to alleviate some of the discomfort caused by this type of labor?

Apply pressure to the client's sacral area during a contraction.

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort?

Applying pressure against her sacrum

What finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.6° C) and 97.4° F (36.3° C) would be considered critical?

Blood glucose level of 36 mg/dL

A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?

Butorphanol (Stadol)

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?

Cervical dilation

A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?

Discontinuing the test because the pattern is within the expected range

A client is admitted in active labor. The nurse, performing Leopold maneuvers, determines that the fetus is in the left occiput anterior (LOA) position. Where should the nurse place the transducer of the electronic fetal monitor?

Left lower quadrant

A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?

Explain why this is expected in early pregnancy.

What is the primary outcome for client care in the third stage of labor?

Firmly contracted uterine fundus

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?

G5 T1 P1 A2 L2

Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward:

Helping the client maintain control

While having contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse do?

Inspect the client's perineum for bulging.

A nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?

One or two fingerbreadths below the umbilicus

A nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client?

Semi-Fowler position to avoid hypotension

A nurse is conducting the admission assessment of a client who is positive for Group B Streptococcus (GBS). Which finding is of most concern to the nurse?

Spontaneous rupture of membranes 3 hours ago

A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?

The cervix is dilated.

What should a nurse include in the discharge teaching of a postpartum client?

The prenatal Kegel tightening exercises should be continued.

A nurse examines a client who had a cesarean birth. It has been 3 days since the birth and the client is about to be discharged. Where does the nurse expect the fundus to be located?

Three fingerbreadths below the umbilicus

A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse tell the client to do?

Use the pant-breathing pattern.

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?

Uterine tetany

A nurse is caring for a client during the early postpartum period. The client alerts the nurse that she is experiencing pain. The nurse interviews the client, obtains her vital signs, and performs a physical assessment. What does this assessment most likely reveal?

Vaginal hematoma

A nurse is assessing a new client in active labor for fetal position. Where will fetal heart tones best be heard if the fetus' position is LOA?

d

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn?

"The esophageal sphincter relaxes and allows acid to be regurgitated."

During a routine visit to the prenatal clinic a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should explain:

"The heart rate is usually rapid, and this one is in the expected range."

A client at 38 weeks' gestation is scheduled for a nonstress test. The woman asks the nurse, "Do you think this test is necessary?" How should the nurse reply?

"You seem to have doubts about this test."

A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at −1 station. Where is the presenting part?

1 cm above the ischial spines

A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this assessment finding to occur?

12th week of pregnancy

A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2011. Using Nägele's rule, what day of June 2012 is the client's estimated date of birth (EDB)? Record your answer using a whole number for the day of the month.

21

A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:

7.5

Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body.

9

During a prenatal examination a nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for:

Acute hemolytic anemia

A client who is lying in the supine position while in active labor is receiving an intravenous oxytocin (Pitocin) infusion and has external monitors in place. Using the monitoring strips below, identify the appropriate nursing interventions. Select all that apply.

Administer oxygen. Turn the client on the side. Discontinue the oxytocin infusion.

A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions:

Come every 5 minutes for an hour

While palpating the fundus of a postpartum client a nurse identifies separation of the abdominal muscles. How should the nurse document this finding?

Diastasis recti

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?

Different cultural groups favor different essential nutrients.

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored?

Hypotensive episodes

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Instruct her to void immediately before the test.

The fetus of a client in labor is found to be at +1 station. Where did the nurse locate the fetus's head?

Just below the ischial spines

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?

Meperidine (Demerol)

A nurse is caring for a client in the transition phase of labor. What breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation?

Panting-blowing pattern

A vaginal examination reveals that a client in labor is dilated 8 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering?

Transition

A client is bleeding excessively after the birth of a neonate. The health care provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin (Pitocin) at a rate of 100 mL/hr. A nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action?

Checking for a distended bladder

A pregnant client is being prepared for a pelvic examination. She reports that she is always tired and feels sick to her stomach, especially in the morning. What is the best response by the nurse?

"Let's discuss ways to resolve these common problems."

During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. What should the nurse advise the client about her position when she sleeps?

"Turn from side to side."

External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?

Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends

Identify the position of the fetus whose buttocks are in the fundus, whose fetal back is on the maternal right side between the midline, and lateral surface of the abdomen, and whose attitude is general flexion.

ROA

When performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position?

ROA

Ten minutes after administering nalbuphine (Nubain) via IV piggyback to a primigravida in active labor, the nurse notes a fetal heart rate of 132 with minimal variability. The client states that the pain is more tolerable and she is able to use her breathing techniques more effectively. Contractions continue every 2 to 3 minutes and are of 60 seconds' duration. What is the nurse's next action?

Document the findings, including the stable fetal heart rate variability after administering the opioid infusion.

A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement?

Donning sterile gloves and applying direct pressure, using sterile gauze

A client who is 38 weeks pregnant presents to the labor unit for a nonstress test (NST). The resulting fetal monitor strip is shown. How does the nurse interpret this finding?

Reassuring; fetal heart rate accelerates with movement

A laboring client expresses concern about the effect that an intravenous analgesic may have on her fetus. The best response by the nurse to reassure the client is:

"It will be administered during a contraction, when the uterine blood vessels are constricted."

What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques.

A primigravida in her 10th week of gestation is concerned because she has read that nutrition during pregnancy is important for the growth and development of the fetus. She wants to know something about the foods she should eat. How should the nurse respond initially?

By asking her what she has eaten over the last 3 days

After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

Appearance of a sudden gush of blood

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located?

Below the ischial spines

After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones?

Below the umbilicus on the right side