ATI Labor and Delivery 2019

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurses's priority? A. pt reports weakness in lower extremities B. BP 80/56 mmHg C. T 38.2 (100.8 F) D. the client reports perfuse itching

B. BP 80/56 mmHg

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? A. monitor pt temp B. assess FHR C. assess odor of amniotic fluid D. provide clean, dry underpads

B. assess FHR

A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? A. observe the color and consistency of fluid B. assess fetal HR pattern C. assess the pt temp D. evaluate the pt for presence of chills and increase uterine tenderness using palpation

B. assess fetal HR pattern BABY

A nurse is caring for a client who in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? A. admin O2 via nasal cannula B. assist the pt to breathe into a paper bag C. have pt tuck chin to chest D. instruct client to increase resp. rate to more than 42 bpm

B. assist the pt to breathe into a paper bag -experiencing resp. acidosis r/t hyperventilation -want to ↑ CO2 level

A nurse is caring for a client with primigravida, at term, and having contractions but is stating she is "not really sure if she is in labor or not". Which of the following should the nurse recognize as a sign of true labor? A. rupture of membranes B. changes in cervix C. station of the presenting part D. pattern of contractions

B. changes in cervix

A nurse is creating the plan of care for a client who is 39 wks and in active labor. Which of the following actions should the nurse include in the plan of care? A. keep 4 side rails up while client is in bed B. check cervix prior to analgesic admin C. monitor FHR every hour D. insert an indwelling urinary cath

B. check cervix prior to analgesic admin

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? A. cocaine use B. hypertension C. blunt force trauma D. cigarette smoking

B. hypertension -all common risk factors, but HTN = most common

A nurse in a hopsital is caring for a client who is at 38 wks and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular FHR of 138/min and no uterine contractions. The clients VS are: BP 98/52, HR 118/min, RR 24/min, T 36.4/97.6 F. Which of the following is the priority nursing action? A. insert indwelling urinary cath B. initiate IV access C. witness the signature for informed consent for surgery D. prepare the abdominal and perineal areas

B. initiate IV access -large bore IV access → admin blood

A nurse in a prenatal clinic is caring for a client who is at 38 wks and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the AM and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving". An US is scheduled stat. The nurse should explain to the client that the purpose of the US is to determine which of the following? A. fetal lung maturity B. location of placenta C. viability of fetus D. biparietal diameter

B. location of placenta

A nurse is caring for a client during a nonstress test (NST). At the end of a 30 min period of observation, the nurse notes the following findings: FHR baseline is 120/min with minimal variability and no accelerations. There are 2 decelerations of 15/min in the FHR during a period of fetal mvmt, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? A. a negative test B. nonreactive test C. positive test D. reactive test

B. nonreactive test -NST that does not produce 2+ qualifying accelerations w/in 20 min = nonreactive

A nurse is admitting a client who is at 36 wks and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? A. abruptio placentae B. placenta previa C. precipitous labor D. threatened abortion

B. placenta previa

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? A. elevate pt legs B. position pt on right side C. admin O2 via facemask D. increase IV infusion rate

B. position pt on right side

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and freq. of 3 min. The nurse obtains the following VS: FHR 130/min, maternal HR 128/min, maternal BP 92/54. Which of the following is the priority actions for the nurse to take? A. notify HCP B. position pt with one hip elevated C. ask pt if she needs pain meds D. have pt void

B. position pt with one hip elevated

A nurse in a provider's office is caring for a client who is at 36 wks gestation and scheduled for an amniocentesis. The client asks why she is having an US prior to the procedure. Which of the following is an appropriate response by the nurse? A. "determines if there is more than one fetus" B. "useful for estimating fetal age" C. "assists in ID the location of placenta and fetus" D. "screening tool for spina bifida"

C. "assists in ID the location of placenta and fetus"

A nurse in a prenatal clinic is instructing a client about aminocentesis, which is scheduled at 15 wks gestation. Which of the following should be included in the teaching? A. "test will be performed if your baby's heart beat is heard" B. "test will determine if your baby's lungs are mature" C. "test required the presence of amniotic fluid" D. "after test, you will be given Rh0 immune globulin since you are Rh positive"

C. "test required the presence of amniotic fluid" -tests the amniotic fluid; not available until after 14 wks -in early preg: determines congenital disorders (neural tube defects, genetic disorders, inborn errors of metabolism) -in late preg: ID fetal lung maturity and fetal hemolytic disease

A nurse is caring for a client who is at 37 wks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary resion should the nurse provide? A. "there is an increased risk of introducing infection" B. "this could initiate preterm labor" C. "this could result in profound bleeding" D. "there is an increased risk of rupture of the membranes"

C. "this could result in profound bleeding"

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examples the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? A. 2 veins, 1 artery B. 1 artery, 1 vein C. 2 arteries, 1 vein D. 2 arteries, 2 veins

C. 2 arteries, 1 vein AVA

A nurse admits a women who is at 38 wks and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9 (102 F). Besides notifying the provider, which of the following is an appropriate nursing action? A. recheck the pt temp in 4 hr B. admin glucocorticoids IM C. assess odor of amniotic fluid D. prepare pt for emergency c-section

C. assess odor of amniotic fluid -chorioamniotitis = infection of amniotic cavity; presents with maternal fever, tachycardia, increased uterine tenderness and foul-smelling amniotic fluid

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? A. assist the client to a comfortable position B. observe the perineum for signs of crowning C. have client pant during next contractions D. help client to bathroom to void

C. have client pant during next contractions -helps pt refrain from pushing before cervix reaches full dilation -7cm too soon for crowning

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? A. admin prescribed analgesic meds B. encourage pt to rest between contractions C. massage the pt back D. turn pt to left side

C. massage the pt back -blocking/preventing transmission of pain signals by using distraction techniques

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? A. apply fundal pressure B. observe for the presence of a nuchal cord C. observe for crowning D. prepare to admin O2

C. observe for crowning -crowning occurs when fetal head is +2, +4 station

A nurse is caring for a client who is having a nonstress test performed. The fetal HR (FHR) is 130 to 150/min, but there has been no fetal movement for 15 minutes. Which of the following actions should the nurse perform? A. immediatly report the situation to the pt provider and prepare pt for induction of labor B. encourage the pt to walk around without the monitoring unit for 10 min, then resume monitoring C. offer the pt a snack of OJ and crackers D. turn the pt to her left side

C. offer the pt a snack of OJ and crackers -nonstress test depends on fetal mvmt -this fetus = asleep -more active after meals

A nurse in a prenatal clinic is caring for a client who is at 38 wks gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? A. there is evidence of cervical incompetence B. there is no evidence of 2 or more accelerations in fetal HR in 20 min C. there is no evidence of uteroplacental insufficiency D. there are less than 3 uterine contractions in a 10 min period

C. there is no evidence of uteroplacental insufficiency

A nurse is admitting a client who is 33 weeks of gestation and has a dx of placenta previa. Which of the following is the priority nursing action? A. monitor vaginal bleeding B. admin glucocorticoids C. insert an IV cath D. apply an external fetal monitor

D. apply an external fetal monitor -maslows = determine if fetus is in distress

A nurse is caring for a client who is at 40 wks and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the clients BP 82/52. Which of the following nursing interventions should the nurse perform? A. prepare cesarean birth B. assist pt to upright position C. prepare for an immediate vaginal deliver D. assist pt to turn to her side

D. assist pt to turn to her side

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? A. apply fetal scalp electrode B. increase rate of IV infusion C. admin O2 10 l/min via nonrebreather D. change pt position

D. change pt position -increase blood flow to fetus

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. maintain the client in the lithotomy position B. perform vaginal examinations frequently C. remind the client to bear down with each contraction D. encourage the pt to empty her bladder every 2 hr

D. encourage the pt to empty her bladder every 2 hr -bladder distension can impede the descent of the fetus and slow the progression of labor

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? A. fetal attitude is in general flexion B. fetal lie is longitudinal C. maternal pelvis is gynecoid D. fetal position is persistent occiput posterior

D. fetal position is persistent occiput posterior

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? A. fetal head is in the left occupit posterior position B. largest fetal diameter has passed through the pelvic outlet C. posterior fontanel is palpable D. lowermost portion of fetus is at the level of the ischial spines

D. lowermost portion of fetus is at the level of the ischial spines -above ischial spines: -1, -2, -3 -below ischial spines: +1, +2, +3

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? A. have pt stand at bedside with arms at side B. admin 500 mL bolus of 5% dextrose in water prior to induction C. inform pt the anesthetic effect will last for approx. 6 hr D. obtain 30 min electronic fetal monitoring strip prior to induction

D. obtain 30 min electronic fetal monitoring strip prior to induction

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients BP is 80/40 mmHg and the fetal HR is 140/min. Which of the following is the priority nursing action? A. elevate the pt legs B. monitor VS Q 5 min C. notify HCP D. place pt in a lateral position

D. place pt in a lateral position -maslows hierarchy → lateral position w pillow under one of pt hips to relieve pressure on IVC and improve BP

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? A. palpate the pt uterus B. admin O2 to pt C. increase pt IV fluid infusion rate D. turn pt to her side

D. turn pt to her side -relieves pressure on IVC

A nurse is observing the electronic FHR monitor tracing for a client who is at 40 wks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes the following patterns? A. early decelerations B. accelerations C. late decelerations D. variable decelerations

D. variable decelerations -umbilical cord becomes compressed -early decelerations = fetal head compression (ex. uterine contractions or fundal pressure) -accelerations = fetal mvmt, vaginal examination, electrode application, fetal scalp stimulation -late decelerations = insufficient placental perfusion during contractions

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? A. presenting part is 1 cm above the ischial spines B. presenting part is 1 cm below the ischial spines C. cervix is 1 cm dilated D. cervix is effaced 1 cm

A. presenting part is 1 cm above the ischial spines

A nurse is caring for a client who is in labor at 40 wks of gestation and reports that she has saturated two perineal pads in the last 30 minutes. A nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? A. examine to determine cervical status B. a mag. sulfate infusion C. initiation of pushing D. preparation for cesarean birth

D. preparation for cesarean birth

A nurse is caring for a group of clients in an intrapartum unit. Which of the following findings should be reported to the provider immediately? A. a tearful pt who is at 32 wks and is experiencing irregular, frequent contractions B. pt 28 wks and receiving terbutaline reports fine tremors C. pt dx preeclampsia has 2+ proteinuria and 2+ patellar reflexes D. pt has dx preeclampsia reports epigastric pain and unresolved headache

D. pt has dx preeclampsia reports epigastric pain and unresolved headache manifestations severe preeclampsia: -BP 160/100 or greater -proteinuria 3+, 4+ -oliguria -visual disturbances -hyperreflexia -N/V, epigastric pain -RUQ pain

A nurse is providing teaching to a client who is at 30 wks and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching? A. "I will have to lie on my back during the test" B. "my babys HR will be monitored during test" C. "i should schedule the test when the baby is usually active" D. "it will take 20-30 min to complete the test"

A. "I will have to lie on my back during the test" -semi fowlers w 1 hip slightly elevated

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? A. contractions lasting longer than 90 seconds B. contractions occurring every 3-5 min C. contractions are strong in intensity D. client reports feeling contractions in lower back

A. contractions lasting longer than 90 seconds -can indicate inadequate uterine relaxation

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply). A. fetal breathing B. fetal motion C. fetal neck translucency D. amniotic fluid volume E. fetal gender

A. fetal breathing B. fetal motion D. amniotic fluid volume fetal neck (aka nuchal translucency, NT) = separate eval gender = ID via ultrasound

A nurse is caring for a client who is at 36 wks and has suspected placenta previa. Which of the following findings supports this dx? A. painless red vaginal bleeding B. increasing abdominal pain with a nonrelaxed uterus C. abdominal pain w scant red vaginal bleeding D. intermittent abdominal pain following passage of bloody mucus

A. painless red vaginal bleeding B = abruptio placenta C = normal labor

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal HR begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? A. place pt in lateral positon B. increase rate of maintenance IV infusion C. elevate pt legs D. admin O2 via nonrebreather

A. place pt in lateral positon -late deceleration associated with fetal hypoxemia r/t insufficient placental perfusion

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicated which of the following? A. uteroplacental insufficiency B. maternal bradycardia C. umbilical cord compression D. fetal head compression

A. uteroplacental insufficiency

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal HR on the monitor strip. Which of the following is a correct interpretation of this finding? A. variable decelerations are due to umbilical cord compression B. variable decelerations are caused by uteroplacental insufficiency C. variable decelerations are result of admin of IV narcotic analgesics D. variable decelerations are r/t fetal head compression

A. variable decelerations are due to umbilical cord compression -uteroplacental insufficiecny produces late decelerations = fetal hypoxemia -fetal head compression produces early decelerations

A nurse in the ED is admitting a client who is at 40 wks gestation, has ruptured membranes, and the nurse observes the newborn's head is crowing. The pt tells the nurse she wants to push. Which of the following statements should the nurse make? A. "you should go ahead and push to assist the deliver" B. "you should try to pant as the delivery proceeds" C. "you should try to perform slow=paced breathing" D. "you should take a deep, cleansing breath and breathe naturally"

B. "you should try to pant as the delivery proceeds" -avoids rapid expulsion of the head slow-paced breathing = first stage of labor as strength/duration of contractions increase cleansing breath/breathing naturally = not alleviate/reduce the urge to push at this time