The Birth Experience

A 31-year-old multigravida client at 39 weeks gestation admitted to the hospital in active labor is receiving IV lactated ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction? A. Hypotension B. Diaphoresis C. Headache D. Tremors

A

A primigravida client is admitted as an outpatient for an external cephalic version. Which factor would be a contraindication for the procedure? A. Multiple gestation B. Breech position C. Maternal Rh-negative blood type D. Hx of gestational diabetes

A

The nurse is discussing pain relief methods for a pregnant first-time mother. The discussion should include which labor support methods? (Select all that apply) A. Effleurage B. Positive reinforcement C. Guided imagery D. Patterned-pace breathing E. Self-containment theory F. Progressive relaxation

A C D F

A 16-year-old primigravida client is admitted at 38 weeks gestation with severe preeclampsia and is given IV mag sulfate and Lactated Ringer's solution. The nurse should obtain what information? A. Urinary output every 8 hours B. Deep tendon reflexes every 4 hours C. RR every hour D. BP every 6 hours

AC

The nurse has obtained a urine specimen from a multiparous client admitted to the labor unit. The woman asks to go to the bathrooms and reports the she feels the urge to move her bowels. Which actions would be appropriate? (Select all that apply) A. Assisting her to the bathroom B. Applying an external fetal monitor to obtain FHR C. Assessing her stage of labor D. Asking if she had back pain like this with her other birth experiences E. Allowing her support person to take her to the bathroom to maintain privacy F. Checking the degree of fetal descent

C F

A 21-year-old primigravida client at 40 weeks gestation is admitted to the hospital in active labor. The client's cervix is 8 cm dilated and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? A. Urinary retention B. Hyperventilation C. Ineffective coping D. Pain

D

A 28-year-old multigravida client at 28 weeks gestation diagnosed with acute pyelonephritis is receiving IV fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which complication? A. Preterm labor B. Maternal sepsis C. Intrauterine growth restriction D. Congenital fetal abnormalities

D

The HCP has informed the labor nurse that he believes the uterus has inverted in a primigravida client who has just given birth. Which findings would help to confirm this dx? (Select all that apply) A. Hypotension B. Gush of blood from the vagina C. Intense, severe, tearing type of abdominal pain D. Uterus is hard and in a constant state of contraction E. Inability to palpate the uterus F. Diaphoresis

A B E F

A client in labor received an epidural for pain management. Before receiving the epidural the client's BP was 124/76 mmHg. Ten minutes after receiving the epidural, the client's BP is 98/56 mmHg., and the mother is vomiting. Before calling the PCP what should the nurse do? A. Decrease the IV fluid rate B. Turn the client to her side Catheterize the client Perform a vaginal exam

B

A multigravida client in labor at 38 weeks gestation has been dx with Rh sensitization and probable fetal hydrops and anemia. Which FHR pattern would the nurse find is most concerning? A. Early decelerations pattern B. Sinusoidal pattern C. Variable decelerations pattern D. Late decelerations pattern

B

A primigravida client is admitted to the labor unit with ruptured membranes and contractions occurring every 2-3 min. lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7-10 min., lasting 30 sec.. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug? A. The cervix will begin to dilate 2 cm/h B. Contractions will occur every 2-3 minutes lasting 40-60 seconds, with moderate intensity resting tone between contractions C. The cervix will change from firm to soft, efface 40-50%, and move from a posterior to an anterior position D. Contractions will be every 2 min., lasting 60-90 sec., with an intrauterine pressure of 70 mmHg

B

During the first hour after a precipitous birth, the nurse should monitor a multiparous client for S/S of which complication? A. Postpartum blues B. Uterine atony C. Intrauterine infection D. UTI

B

The primigravida client is at +1 station and 9cm dilated. Based on these data, what should the nurse do first? A. Ask the anesthesiologist to increase the epidural infusion rate B. Assist the client to push if she feels the need to do so C. Encourage the client to breathe through the urge to push D. Support family members in providing comfort measures

C

third leopold maneuver

Determining which fetal part lies over the pelvic inlet to identify fetal attitude. Use right hand to grasp lower section of patient's abdomen between index finger and thumb and press inward over inlet to true pelvis. Note any movement and determine whether the presenting part is soft or firm. If there is movement, the presenting part is not engaged. If the head is the presenting part, determine fetal attitude, that is, whether the head is flexed or extended.

A nurse begins the shift on the obstetrical unit, there are several new admissions. The client with which condition would be a candidate for induction? A. Preeclampsia B. Active herpes C. Face presentation D. Fetus with late decelerations

A

Which technique to promote active relaxation would the nurse include in the teaching plan for a 16-year-old primigravida client in early labor? A. Relaxing uninvolved body muscles during uterine contractions B. Practicing being in a deep, meditative, sleep-like state C. Focusing on an object in the room during the contractions D. Breathing rapidly and deeply between contractions

A

The nurse is performing a vaginal examination on a client in labor. The nurse finds the fetal presenting part 1 cm above the ischial spines. How should the nurse document the fetal station? A. -1 station B. +1 station C. Engaged D. Floating

A

The HCP has performed an amniotomy on a laboring client. Which details must be included in the documentation of this procedure? (Select all that apply) A. Time of rupture B. Color and clarity of fluid C. FHR and pattern before and after the procedure D. Size of amnio hook used during the procedure E. Odor and amount of fluid

A B C E

Assessment of a primigravida client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? A. Excitement B. Loss of control C. Numbness of the legs D. Feelings of relief

B

The HCP prescribes intermittent fetal heart rate monitoring for a 20-year-old obese primigravida client at 40 weeks gestation in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which interval? A. Every 15 min. during the latent phase B. Every 30 min. during the active phase C. Every 60 min. in the pushing phase D. Every 2 hours during the transition phase

B

The nurse has received a telephone call from the ER indicating that a multigravida client in early labor and diagnosed with probable placenta previa will be arriving soon. What is the priority intervention when the client arrives to the unit? A. Whole blood replacement B. Continuous BP monitoring C. Internal FHR monitoring D. An immediate cesarean birth

B

The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks gestation and weighs 9 lbs. Assessing for S/S of which condition should be a priority in this neonate? A. Anemia B. Hypoglycemia C. Delayed meconium D. Elevated bilirubin

B

The GCP determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean birth with general anesthesia. Before the cesarean birth the anesthesiologist prescribes cimetidine 300 mg PO. The nurse explains that the purpose of giving cimetidine is to decrease which factor? A. Incidence of bronchospasm B. Oral and respiratory secretions C. Acid level of the stomach contents D. Incidence of post-op gastric ulcer

C

The HCP has prescribed prostaglandin gel to be administered vaginally to a newly admitted primigravida client. Which finding indicates that the client has had a therapeutic response to the medication? A. Resting period of 2 minutes between contractions B. Decreasing nausea in labor C. Softening of the cervix and beginning of effacement D. Leaking of clear amniotic fluid in small amounts

C

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking Ginko Biloba to help maintain her blood sugars. The nurse notifies the HCP because this herbal supplement puts the client at risk for what complication? A. Medication interactions B. Hypertensive crisis C. Over sedation D. Prolonged bleeding

D

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? A. Acme of one contraction to the beginning of the next contraction B. Beginning of one contraction to the end of the next contraction C. End of one contraction to the end of the next contraction D. Beginning of one contraction to the beginning of the next contraction

D

While a client is being admitted to the birthing unit, she states "My water broke last night, but my labor started 2 hours ago ." Which findings are a concern? (Select all that apply) A. Maternal VS: T (99.5F), HR (80), RR (24), BP (130/80) B. Blood and mucus on perineal pad C. Baseline FHR of 140 bpm with a range between 110-160 bpm with contractions D. Peri pad stained with green fluid E. Client stating, "This baby wants out- he keeps kicking me."

C D E

A multigravida client in active labor at term is dx with polyhydramnios. The HCP has instructed the client about possible neonatal complications r/t the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which problem in an fetus or neonate? A. Renal dysfunction B. Intrauterine growth restriction C. Pulmonary hypoplasia D. GI disorders

D

The HCP prescribes amnioinfusion for a primigravida client at term who is dx with oligohydramnios. What does the nurse explain s the primary purpose of the procedure to the client? A. Decreases the frequency and severity of variable decelerations B. Minimizes the possibility of fetal metabolism alkalosis C. Increases the FHR accelerations during a contraction D. Raises the amniotic fluid index to more than 15 cm

A

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in what position? A. Lithotomy B. Right lateral position C. Hands and knees D. Tailor sitting

C

A primigravida client in early labor with abruptio placentae develops DIC. Which agent should the nurse expect the HCP to prescribe? A. Magnesium sulfate B. Warfarin Sodium C. Fresh frozen platelets D. Meperidine hydrochloride

C

Approximately 15 minutes after birth of a viable term neonate, a multiparous client has chills. What should the nurse do next? A. Assess the client's pulse rate B. Decrease the rate of IV fluids C. Provide the client with a warm blanket D. Assess the amount of blood loss

C

The nurse is performing effleurage for a primigravida client in early labor. Which technique should the nurse use? A. Deep kneading of superficial muscles B. Secure grasping of muscular tissues C. Light stroking of the skin surface D. Prolonged pressure on specific sites

C

The nurse is preparing to assist the HCP with a cervical check for a client whose membranes have ruptured. What equipment should the nurse have ready for the HCP? (Select all that apply) A. Sterile speculum B. Sterile gloves C. Sterile lubricant D. Amnio hook E. Cervical dilators

B C

The cervix of a primigravida client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. What is most important for the nurse to assess before the client is ready to push? A. Fetal heart rate variability B. Cervical dilation again C. Status of the membranes D. Bladder status

D

A primigravida client at 39 weeks gestation is admitted to the hospital for induction of labor. The HCP has prescribed a prostaglandin E2 gel for the client. Before administering the prostaglandin E2 gel to the client the nurse should perform what action first? A. Assess the frequency of uterine contractions B. Place the client in the side-lying position C. Determine whether the membranes have ruptured D. Prepare the client for an amniotomy

A

A primigravida client at 39 weeks gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the clients cervix is still dilated at 6cm with 100% effacement at +1 station. Contractions are 3-5 min. apart, lasting 45 sec., and of moderate intensity. The nurse determines that the client is most likely experiencing which problem? A. Cephalopelvic disproportion B. Prolonged latent phase C. Prolonged transitional phase D. Hypotonic contraction pattern

A

A primigravida client in active labor has had no anesthesia. The client's cervix is 7 cm dilated and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to what breathing technique? A. Rapid, shallow chest breathing B. Deep chest breathing C. Rapid pant-blowing breathing D. Slow abdominal breathing

A

For the past 8 hours, a 20-year-old primigravida client in active labor with intact membranes has been experiencing regular contractions. The FHR is 136 bpm with moderate variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for what problem? A. Exhaustion B. Fever and chills C. Fluid overload D. Meconium-stained fluid

A

The nurse explains to a newly admitted primigravida client in active labor that, according to the gate-control theory of pain, a closed gate measurement means that the client is experiencing what kind of pain? A. No pain B. Sharp pain C. Light pain D. Moderate pain

A

The nurse in the labor and delivery unit receives a telephone call from the ED announcing that a multigravida client in active labor is being transferred to the labor area, The client has no perinatal care. When the client arrives by stretcher, she says "I think the baby is coming." The fetal skull is crowning. The nurse should obtain what information first? A. Estimated date of birth B. Amniotic fluid status C. Gravida and parity D. Prenatal history

A

The nurse assists with a precipitous birth in an outpatient setting. While waiting for more advanced care, the nurse places the infant skin-to-skin with the mother and encourages breastfeeding. What are the desired outcomes of skin-to-skin care with early breastfeeding? (Select all that apply) A. Beginning the parental-infant bonding process B. Preventing neonatal Hypothermia C. Providing glucose to the neonate D. Contracting the mothers uterus E. Preventing maternal infection

A B C D

The nurse has just received report on a labor client: G3, T1, P0, A1, L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shift will address which factors? (Select all that apply) A. Birth should occur before the change of shift in 12 hours B. Stage 2 should take 30 min. or less C. Contractions will remain irregular until transition D. Transition will be shorter for this multiparous client E. The client will withdraw into herself during the transition

A B D E

What actions does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? (Select all that apply) A. Assigning the APGAR scores B. Administering O2 C. Assisting with perineal repairs D. Drying the newborn E. Initiating skin-to-skin care F. Taking newborn VS

A D E F

The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse tells the client to assume what position? A. Lithotomy B. Side-lying C. Hands and knees D. Prone

B

Assessment of a primigravida client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this stage of labor. The nurse explains that the client's severe back pain s most likely caused by the fetal occiput being in which position? A. Breech B. Transverse C. Posterior D. Anterior

C

The nurse is managing care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client? A. O2 Sat. monitoring every half hour B. Supine positioning on back, if it is comfortable C. Anesthesia/pain level assessment every 30 min. D. Vaginal bleeding, rupture of membranes assessment every shift

C

While assessing a primigravida client at 36 weeks gestation observes bruises at multiple stage of healing. The client admits her boyfriend beats her and states that she wants to leave him but is afraid. Which action is most appropriate by the nurse? A. Tell the client to leave the BF immediately B. Ask the client when she last felt the baby move C. Refer the client to the social worker for possible options D. Report the incident to the unit nursing supervisor

C

The nurse is caring for a G2, T1, P0, A0, L1 client at term. The client is completely effaced, dilated to 2 cm, with contractions every 3 minutes lasting 45 seconds. The client is asking for an epidural to make her more comfortable. Indicate the appropriate response by the nurse. A. We cannot give epidurals until you are 5-6 cm dilated. There is IV medication available if you would like it now B. You cannot have an epidural until your membranes have ruptured C. Your contraction pattern is slow at this point and you will need to accelerate before you can have an epidural D. It is too early in labor for the epidural, but you can have IV medications to keep you comfortable until you have dilated 1-2 cm more

D