Unit 2: High-risk Intrapartum 3/5
A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm 3 and a hematocrit of 29%. Her laboratory values 1 week earlier were platelet count 200,000 cells/mm 3 and hematocrit 37%. Which additional abnormal laboratory value would the nurse expect to see?
Elevated alanine transaminase (ALT)
In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion?
Meconium-stained fluid
An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms?
Hemorrhage
The doctor writes the following order for a 31-week-gravid client with symptomatic placenta previa: Weigh all vaginal pads and estimate blood loss. The nurse weighs one of the client's saturated pads at 24 grams and a dry pad at 4 grams. How many milliliters (mL) of blood can the nurse estimate the client has bled? Calculate to the nearest whole number.
20 mL
A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective?
Client has no grand mal seizures
A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client?
Coughing and deep breathing
During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time?
Flex the woman's thighs sharply toward her abdomen
Which of the following physical findings would lead the nurse to suspect that a client with severe pre-eclampsia has developed HELLP syndrome? Select all that apply.
Petechiae Jaundice
Which of the following situations should the nurse conclude is a vaginal delivery emergency?
Shoulder dystocia
A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question?
Assess cervical dilation
A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: Prothrombin time (PT) 99 sec (normal 60 to 85 sec) Partial thromboplastin time (PTT) 30 sec (normal 11 to 15 sec) For which of the following signs/symptoms would the nurse monitor the client?
Pink-tinged urine
Which of the following laboratory values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome?
Platelets 75,000
A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following?
Presence of abdominal pain
The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish-colored amniotic fl uid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time?
Risk for fetal injury related to possible intrauterine hypoxia
A client is on magnesium sulfate for severe pre-eclampsia. The nurse must notify the attending physician regarding which of the following findings?
Serum magnesium level of 9 g/dL
The nurse is monitoring a woman, G2 P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; −3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; −3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude?
The woman is likely carrying a macrosomic fetus
During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record?
Through the rectal sphincter
A nurse is monitoring a client who is receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make to prevent a serious complication related to the procedure?
Uterine resting tone
A client who has been diagnosed with severe pre-eclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room?
Calcium gluconate
A woman with severe pre-eclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion?
Duration of contractions of 130 seconds
A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following orders by the primary healthcare provider should the nurse question?
Begin oxytocin drip rate at 0.5 milliunit/min
The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform?
Pad the client's bed rail and headboard
After a multiparous woman has been in active labor for 15 hours, an ultrasound is done. The results state that the obstetric conjugate is 10 cm and the suboccipitobregmatic diameter is 10.5 cm. Which of the following labor findings is related to these results?
Station of -3